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 & processesEnsure patient safety at all times according to Hospital policies.Ensure that patient privacy & confidentiality is duly protected at all the timesAchieve 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 meetingsTo communicate the observations, non- compliance, issues and challenges compiled from all possible information sources towards compliance to quality standards to Chief Nursing OfficerTo 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 OfficerParticipate as per defined role during any internal and external disasterParticipate in the emergency incident response activities as defined within the emergency response team manual as and when required at the direction of managementMonitor and check all equipment calls and PM date within their department and attend to escalations if not done within defined timeCheck the timely documentation of Nurses within unit for vitals, assessments, reassessment, handover, care bundles, drug administrationMonitoring and intervening appropriate acuity based staffingResponsible for competency assessment along with Nurse educatorsTraining need identification and execution along with Nurse educatorsAttend to Safety HuddlesEnsure timely SLOC inventory and stock levels monitoringResponsible for Inventory management of equipment, Supplies for the Quality deptEnsure and monitor compliance to IPSG by the Nursing StaffTake daily patient rounds for clinical and service gaps such as delays in care/servicesAny 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 improvementSupport 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 resourcesEnsure 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 consumptionEnsure 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 deptSupport the Nursing Leadership & HR in selection and onboarding of the most suitable and competent team membersSet the goals of the team members and drive high performance and professional excellenceIdentify 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 / issuesCo-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 standardsProvides 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 carePlan 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
ExcellenceAccountabilityRespectOne TeamIntegrity
- Function-specific Competencies (Technical /Functional)
Customer OrientationCommunication SkillsInterpersonal SkillsBusiness EtiquettesKnowledge of organizational and infection control policies and proceduresEffective implementation of strategiesKnowledge about JCI & NABH standardsUse of HISPatient Safety
Competencies
Patient First
ExcellenceAccountabilityRespectOne TeamIntegrity
- Function-specific Competencies (Technical /Functional)
Knowledge of department procedures
knowledge about latest development in the concerned nursing fieldKnowledge & use of applicable equipmentInfection prevention and controlKnowledge about JCI & NABH standardsUse of HISPatient SafetyManagerial SkillsMedication ManagementPain ManagementCommunication 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 instituteCertification 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 timeRequired 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 PerformanceMonitoring deviation from standard nursing practicesPatient 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 ErrorsNear missAudit observations by Quality Rounding & daily auditContribution towards financialVariance on expenditure - Budgeted Vs. ActualsTraining of team members% Adherence to training calendarNo. of training hoursThe above are broad KRAs and KPIs. These will be reviewed & set every year as per operational needs
