Skills:
Clinical Quality Improvement, JCI Accreditation, Nursing Leadership, Policy Development, Audit Management, Compliance Monitoring, Process Improvement, Root Cause Analysis,
Develop and support continuous quality improvement activities at organizational & departmental level to assist ,evaluate ,analyse & improve work process & outcomes ensuring the participation of employees
To evaluate compliance to accreditation standards and quality in general and ensure implementation of corrective and preventive action in patient care areas.
Monitor quality & safe nursing care & strive for continuous excellence in nursing outcomes.
Key Responsibilities: Service
Support the Nursing Leadership in delivery of nursing care in conformance with the Sir HN RFH policies & processes
Ensure patient safety at all times according to Hospital policies.
Ensure that patient privacy & confidentiality is duly protected at all the times
Achieve and maintain quality standards in conformance with customer requirement.
To evaluate the scope of improvements in the nursing service related activities and maintaining quality standards in patient care areas.
To provide guidance to the staff, counsels them in quality improvement activities and patient safety programs.
Ensure that employees to complete awareness of the quality system and orientates new employees to the system.
Plan Internal Audit calendar for ongoing Quality Audits and ensure that internal audits are conducted as per the schedule or as required.
Lead, plan and participates & assist in the organization of regularly scheduled management review meetings
To communicate the observations, non- compliance, issues and challenges compiled from all possible information sources towards compliance to quality standards to Chief Nursing Officer
To give feedback to the Nurse Managers, Ward Managers of areas of concern/ action and work collaboratively with them for successful implementation of re-dressal measures.
Review / Compile and summarize Nursing Quality data for presentation at monthly departmental meetings as requested.
Take regular hospital rounds to observe quality & patient safety standard compliances and precautions.
Maintain confidentiality of the employee, area of work place and patient in the internal audit reports.
Ensure capacity building of the nursing staff by identifying scope for training and working collaboratively with the Ward Manager in implementing them.
To collect, tabulate the data pertaining to quality indicators and co-ordinate with the concerned floors and understand the reason for deviation.
To ensure implementation of corrective measures towards improvement in quality as approved.
Review / Generate regular reports regarding the adherence to quality standards, achievements and possibility of improvement, and submit to Chief Nursing Officer.
Prepare / review and publish of Quality and safety dashboard.
Draft and submit nursing policies and protocols pertaining to quality standards in collaboration with Dy CNO - Excellence Chief Nursing Officer
Participate as per defined role during any internal and external disaster
Participate in the emergency incident response activities as defined within the emergency response team manual as and when required at the direction of management
Monitor and check all equipment calls and PM date within their department and attend to escalations if not done within defined time
Check the timely documentation of Nurses within unit for vitals, assessments, reassessment, handover, care bundles, drug administration
Monitoring and intervening appropriate acuity based staffing
Responsible for competency assessment along with Nurse educators
Training need identification and execution along with Nurse educators
Attend to Safety Huddles
Ensure timely SLOC inventory and stock levels monitoring
Responsible for Inventory management of equipment, Supplies for the Quality dept
Ensure and monitor compliance to IPSG by the Nursing Staff
Take daily patient rounds for clinical and service gaps such as delays in care/services
Any other responsibility as assigned by the organization on the need basis.
Key Responsibilities: Growth
Actively participate in all growth strategies defined by the hospital.
Ensure effective utilization of available resources to support management of increased growth.
Ensure good clinical outcomes to maintain defined ALOS of patients
Key Responsibilities: Quality
Lead, participate and drive all quality assurance and patient safety related activities of the Nursing department to ensure continuous quality improvement
Support and monitor the entire Nursing team in achieving and sustaining accreditation standards like NABH and JCI etc.
Maintain Nursing Quality Indicators and various audit information. Monitor trends, identify areas of deviations and recommend remedial actions to the CNO
Key Responsibilities: Finance
Monitor and ensure optimal utilization of available resources
Ensure nursing manpower is effectively utilized as per the patient mix, volume and specialties.
Monitor and ensure the inventory management process and ensure the inventory is appropriate and the stock variances should be optimum or <2. Oversee the consumptions of the departments are done weekly.
Ensure the consumables and other materials are utilized judiciously and not causing unwanted consumption
Ensure the biomedical equipments and other instruments of the departments are utilized appropriately without any damages and loss.
Ensure the Preventive maintenance and functionality of all equipments in coordination with biomedical department
Key Responsibilities: People
Support the DCNO in selection of the most suitable resources for the Quality dept
Support the Nursing Leadership & HR in selection and onboarding of the most suitable and competent team members
Set the goals of the team members and drive high performance and professional excellence
Identify clinical and behavioral developmental needs of the team, and collaborate with the Nurse Educator to create a Training & Development Plan.
Ensure continuous up gradation and enhancement of functional and technical skills of the team members through implementation of effective professional training / programs.
Ensure high morale of the team through timely resolution of any grievances / issues
Co-ordinate with HR and training cell to ensure employees complete awareness of the quality system and orientates new employees to the system.
Co-ordinate with HR and training cell to ensure employees complete awareness of the vision, mission and goals of Sir HN RFH and works towards maintaining quality standards
Provides guidance to the nursing staff, counsels them in quality improvement activities and patient safety programs.
Initiates & coordinates emergency, patient safety practices and fire safety measures as appropriate.
Key Responsibilities: Innovations and Research
Identify and suggest new ideas/ feedback to enhance departmental operations and patient care
Plan and participate in clinical education, research, test medication and clinical tests to advance the practice of nursing as well as academic and teaching activities as required by the hospital.
Competencies
Patient First
Excellence
Accountability
Respect
One Team
Integrity
- Function-specific Competencies (Technical /Functional)
Customer Orientation
Communication Skills
Interpersonal Skills
Business Etiquettes
Knowledge of organizational and infection control policies and procedures
Effective implementation of strategies
Knowledge about JCI & NABH standards
Use of HIS
Patient Safety
Competencies
Patient First
Excellence
Accountability
Respect
One Team
Integrity
- Function-specific Competencies (Technical /Functional)
Knowledge of department procedures
knowledge about latest development in the concerned nursing field
Knowledge & use of applicable equipment
Infection prevention and control
Knowledge about JCI & NABH standards
Use of HIS
Patient Safety
Managerial Skills
Medication Management
Pain Management
Communication and Interpersonal Skills
- Experience & Educational Requirements
EDUCATIONAL QUALIFICATIONS:
Include Additional Certification Required if any
Necessary:
- B.Sc. in Nursing from a recognized nursing institute
- Should have nursing council registration
Desirable:
MSc.in Nursing from a recognized nursing institute
Certification course BLS/ACLS
RELEVANT EXPERIENCE:
Type of roles (and duration) which an individual ideally should have done in his/her prior experience to be detailed
Necessary:
- 15+ years of nursing experience out of which minimum 5 yrs. In Quality managerial roles
- Exposure to JCI / NABH
Desirable:
- Scope of Work
- Financial Scope (Range of financial spend):
- NA
- People Management Scope (Range of no. of Direct Reports):
- Team of Staff Nurses and PCAs
- Corporate Coverage (hospital-wide / sub-function-wide / area wide):
- Across the Hospital
- Working Conditions
Possible exposure to communicable diseases, hazardous materials, radiation and pharmacological agents.
Work requires standing and /or walking for extended period of time
Required to adhere to work availability and unit scheduling requirements or on call
- Key Performance Areas & Key Performance Indicators
Key Result Areas
Key Performance Indicators
Nursing Care Performance
Monitoring deviation from standard nursing practices
Patient Satisfaction Index on nursing care
Nursing Services Core Indicators :
- Cases wherein the nursing care plan is documented
- Incidents of falls
- Incidents of bed sores after admission
- Nurse- Patient ratio for ICUs and wards
- Time for initial assessment of indoor patients
- Appropriate Hand Off during shift change
Accidental delining
Medication Administration Errors
Near miss
Audit observations by Quality Rounding & daily audit
Contribution towards financial
Variance on expenditure - Budgeted Vs. Actuals
Training of team members
% Adherence to training calendar
No. of training hours
The above are broad KRAs and KPIs. These will be reviewed & set every year as per operational needs
