Job Description

Leadership & Patient Rights:
● Demonstrates understanding and respect for the rights, dignity, and individuality of each patient in all interactions.
● Demonstrates effective leadership skills including critical thinking, problem solving, decision-making, delegation, strategic planning, project management, and mentoring.
● Allocates resources to meet department needs and assumes responsibility for nursing services in the absence of the CNO.

Quality, Safety, & Risk Management:
● Establishes comprehensive mechanisms to improve clinical outcomes and patient safety, and uses data analysis for proactive risk reduction to reduce the risk of sentinel events.
● Coordinates the Quality Assessment and Performance Improvement Committee of the Whole as the focal point for exchanging patient safety information.
● Serves as the Risk Manager, trends incident reports, manages survey preparation, and ensures ongoing compliance and survey readiness.
● Monitors compliance with policies, standards, and regulations set by the Board, Medical Staff, and accrediting bodies, while ensuring accurate and timely reporting of CMS and NHSN quality data.
● Ensures accurate and timely reporting of CMS Quality Measures.

Education & Training:
● Plans, coordinates, and teaches general and clinical hospital orientation, updating competency checklists and ensuring mandatory policies are provided to new employees.
● Develops individualized education plans for new hires and plans discipline-specific preceptorship programs, following up to ensure relationships progress as planned.
● Provides hospital-wide in-service education related to the care of adult patients (18+), new equipment, and policy changes.
● Serves as the HealthStream Administrator, building custom courses and ensuring all shifts have access.
● Modifies training and education programs in response to nursing outcomes and performance improvement findings.

Infection Control & Employee Health:
● Serves as the Infection Control Practitioner and Employee Health Nurse.
● Conducts regular surveillance to prevent and control infections and educates staff on evidence-based prevention practices.

Corporate Compliance:
● Provides direction and oversight for the Hospital Compliance Program, identifying compliance risks, distributing the written Code of Conduct, developing education programs, and overseeing an anonymous, retaliation-free reporting process.

Education/Experience: Current RN license to practice in the state. Requires 2+ years of hospital educator experience and prefers 2 years of experience with Quality Management. Master’s degree preferred.
Certifications: Current ACLS and BLS certification (or must obtain BLS within 30 days and ACLS within 90 days of employment).