Nursing Clinical Excellence Policy


The Nursing Clinical Excellence Program was created to recognize and reward commitment to and expertise in clinical practice for the RN employed as a staff nurse at the Methodist Healthcare System. It is designed to foster self-growth in leadership, to reward quality patient care, teaching, education and evidence based practice standards. It promotes exceptional customer service and team collaboration within the Methodist Excellence model.


Program Overview

The Nursing Clinical Excellence Program provides eligible Registered Nurses (criteria described in next section) the option to progress on a clinical career ladder consisting of a number of position levels through the achievement of designated credentials, achievements and contributions. Registered Nurses are provided descriptive information of the qualifying criteria for achievement at each level and, if eligible, may opt to participate in the program and determine the level that they would like to strive to reach. The achievement of each level on the ladder will correspond with a wage adjustment to the RN’s base wage rate. Once each level is initially achieved, the RN must, on an annual basis, meet certain requirements to retain the current level or move up to the next one. There will be four designated time periods each calendar year when eligible RNs may submit their documentation to join the program or achieve a higher level. Documentation to maintain a current level will be submitted to the Director by the RN at the time of his/her annual evaluation. The RN is responsible for accurately completing the required paper work and submitting it during the required time frame.

All Registered Nurses will be hired at Level I or II. These positions are not considered to be part of the advancement ladder. While clinical progression is encouraged, staff nurses maintain the option to remain at the RN II level without upward progression.

Those who meet the following criteria may participate in the program and seek to obtain and maintain the levels of RN III and RN IV.

  • Registered Nurse delivering direct patient care
  • Demonstrates basic knowledge of the nursing process in the care of patients as described in the Texas Nursing Practice Act and American Nurses Association Scope of Practice
  • Successfully completes the Nursing internship/orientation program
  • Completion of yearly mandatory and CEU licensure requirements including mandatory hospital events (i.e., Code of Conduct, TB screening, annual educational requirements, etc.)
  • RN for at least 2 years
  • Minimum of one year Methodist Healthcare System RN experience and also worked a minimum of 1000 hours within the year of application
  • Adheres to the Methodist Excellence standards and Code of Conduct
  • Must not be under work improvement plan or have attendance issues or disciplinary action within the last 12 months.
  • Consistently demonstrates professional behavior including respectful, open communication with the healthcare team
  • Is an exemplary role model of clinical practice and leadership for staff and peers
  • Acts as an integral member of the team and promotes team work and problem solving to deliver quality patient care
  • Manages problems and issues to resolution

Nurses that are not eligible include clinical nurse specialists, nurse clinicians, case managers, nurse directors, prn nurses, salaried exempt nurses, and nurse practitioners.

Nursing Career Progression

The four position levels in which an eligible RN will be classified include:

  • Level I
    RN/GN prior to NCLEX–RN satisfactory completion, six months employment and satisfactory completion of orientation
  • Level II
    RN new hires and RNs who choose not to progress in Clinical Excellence Program
  • Level III**
  • Level IV**

**Is considered a level in the Nursing Clinical Excellence Program

The RN/GN and RN II levels are not considered levels in the Nursing Clinical Excellence Program. RNs are not required to join the Nursing Clinical Excellence Program (achieve RN III or RN IV status), but if they choose to join the program they must achieve and maintain all criteria to retain their title and associated rate of pay. RNs can only advance one level per 12 month period.

The Nursing Clinical Excellence Program allows eligible RNs to select from a menu of activities and achievements in order to earn the points needed to qualify for either the RN III or RN IV levels. These criteria are organized using the Methodist Excellence pillars including Education, Service, Leadership and Quality Improvement. Points must be earned in at least three of the four pillars. This document should serve as a guide to RNs as they plan their activities during the year that are focused toward the goal of attaining or maintaining the designation of RN III or RN IV.

Initial Participation in the Program

The RN III or RN lV levels require that the eligible RN present documentation to support the achievement of specific credentials and activities. These requirements are described in a separate document titled, “Methodist Healthcare System-Clinical Excellence Program for RNs”. Eligible Registered Nurses will have the opportunity during the four designated time periods each calendar year to present the supporting information and documentation.

Maintaining Current Position Level

Eligible RNs who have achieved the levels of RN III or RN IV will be required to take steps throughout the year to maintain that position level. This revalidation will be based on the same criteria as used for the initial validation. Eligible RNs will present the documentation supporting their achievement of the criteria at the time of their annual evaluation.

Advancing to a Higher Level

Eligible RNs who are interested in advancing from RN III to RN IV are required to provide documentation supporting their achievement of the criteria required for the RN IV level. They will submit this documentation during one of the four designated time periods and no sooner than 12 months from their attainment of the previous level.

RNs in Clinical Excellence Program that Leave and Return to MHS

If an RN re-applies to MHS within six (6) months of voluntarily resigning, they can return to the same level they had prior to leaving. If it has been over six (6) months, they will start as a RN II and remain at that level for one year before being eligible for advancement.

Transferring to Another Department

RNs that transfer to another department will retain their current level and must validate their level at their annual evaluation period. They must be in that department for at least one year to apply for advancement.

Failure to Validate Current Position Level

Eligible RNs, who are unable to provide documentation supporting the maintenance of their current levels, may be granted a 30 day extension (from date of performance assessment) to acquire this documentation. If the RN fails to provide the required documentation, he/she will be placed in the level for which he/she can provide supporting information. If no information is provided, the RN will be reclassified as a RN ll. The RN’s hourly wage rate will be adjusted in collaboration with human resources.


  • Initial Program Participation/Advancing to a Higher Level
    1. >Registered Nurses will review the program eligibility requirements to determine if they may apply for participation in the program. They may refer any questions they have about their eligibility to their directors or to a liaison.
    2. Upon determining that they are eligible, RNs will review the criteria for each of the levels and determine which level they will aspire to achieve.
    3. Eligible RNs will determine during which of the designated time periods for the calendar year they would like to submit their applications.
    4. RNs will work toward achieving the number of points required under at least 3 of the 4 Methodist Excellence (ME) pillars and will document these achievements in their portfolio. RNs will submit their completed paperwork to their Manager/ Director during the designated time period. The Manager/Director will provide a letter of support.
    5. The RN will make an appointment with a liaison at least two weeks prior to HR submission date. The liaison will review the paperwork and determine the need for any additional information. They will provide a letter of support. Completed application packets will include:
      • Completed applicant checklist
      • Portfolio with documentation of points
      • Letter of support from manager/director
      • Application for Clinical Excellence program
      • Clinical Excellence program scoring tool
    6. Once packet is reviewed by the liaison, the RN will submit the completed packet to Human Resources.
    7. The Clinical Excellence Committee reviews packets and determines eligibility for advancement.
    8. RNs advancing will receive a certificate formally acknowledging their achievement.
  • Maintaining Current Program Level
    1. RNs will submit their completed paperwork to their director during their annual evaluation period.
    2. Directors will review the paperwork and determine the need for any additional information in order to validate the request. Completed application packets will include:
      • Portfolio with documentation of points
      • Nursing Clinical Excellence Program scoring tool
    3. Once validation is confirmed, Directors will submit packets with the Performance Feedback to Human Resources for filing.
    4. Random audits will be done of maintenance packets to maintain the integrity of the program. Audits will be performed by the Clinical Excellence Committee.
    5. Directors will communicate with validating RNs any discrepancies, questions or concerns about the paperwork submitted and will work collaboratively with the RN to resolve those as soon as possible.

Appendix A

Nursing Clinical Excellence Yearly Designated Application Time Periods
Eligibility Due to Liaison Due to Human Resources Increase Effective Date
1st quarter Jan 1-March 31 January 15th February 1st First complete pay period in March
2nd quarter April 1-June 30 April 15th May 1st First complete pay period in June
3rd quarter July 1-Sept 30 July 15th August 1st First complete pay period in September
4th quarter Oct 1-Dec 1 October 15th November 1st First complete pay period in December