1. Job Purpose

·        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.

2. Accountabilities

Key Responsibilities: Service

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Support the Nursing Leadership in delivery of nursing care in conformance with the Sir HN RFH policies & processes

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Ensure patient safety at all times according to Hospital policies.

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Ensure that patient privacy & confidentiality is duly protected at all the times

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Achieve and maintain quality standards in conformance with customer requirement.

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To evaluate the scope of improvements in the nursing service related activities and maintaining quality standards in patient care areas.

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To provide guidance to the staff, counsels them in quality improvement activities and patient safety programs.

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Ensure that employees to complete awareness of the quality system and orientates new employees to the system.

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Plan Internal Audit calendar for ongoing Quality Audits and ensure that internal audits are conducted as per the schedule or as required.

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Lead, plan and participates & assist in the organization of regularly scheduled management review meetings

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To communicate the observations, non- compliance, issues and challenges compiled from all possible information sources towards compliance to quality standards to Chief Nursing Officer

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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.

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Review / Compile and summarize Nursing Quality data for presentation at monthly departmental meetings as requested.

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Take regular hospital rounds to observe quality & patient safety standard compliances and precautions.

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Maintain confidentiality of the employee, area of work place and patient in the internal audit reports.

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Ensure capacity building of the nursing staff by identifying scope for training and working collaboratively with the Ward Manager in implementing them.

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To collect, tabulate the data pertaining to quality indicators and co-ordinate with the concerned floors and understand the reason for deviation.

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To ensure implementation of corrective measures towards improvement in quality as approved.

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Review / Generate regular reports regarding the adherence to quality standards, achievements and possibility of improvement, and submit to Chief Nursing Officer.

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Prepare / review and publish of Quality and safety dashboard.

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Draft and submit nursing policies and protocols pertaining to quality standards in collaboration with Dy CNO – Excellence Chief Nursing Officer

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Participate as per defined role during any internal and external disaster

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Participate in the emergency incident response activities as defined within the emergency response team manual as and when required at the direction of management

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Monitor and check all equipment calls and PM date within their department and attend to escalations if not done within defined time 

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Check the timely documentation of Nurses within unit for vitals, assessments, reassessment, handover, care bundles, drug administration 

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Monitoring and intervening appropriate acuity based staffing

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Responsible for competency assessment along with Nurse educators

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Training need identification and execution along with Nurse educators

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Attend to Safety Huddles

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Ensure timely SLOC inventory and stock levels monitoring 

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Responsible for Inventory management of equipment, Supplies for the Quality dept

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Ensure and monitor compliance to IPSG by the Nursing Staff

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Take daily patient rounds for clinical and service gaps such as delays in care/services

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Any other responsibility as assigned by the organization on the need basis.

Key Responsibilities: Growth

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Actively participate in all growth strategies defined by the hospital.

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Ensure effective utilization of available resources to support management of increased growth.

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Ensure good clinical outcomes to maintain defined ALOS of patients

Key Responsibilities: Quality

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Lead, participate and drive all quality assurance and patient safety related activities of the Nursing department to ensure continuous quality improvement

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Support and monitor the entire Nursing team in achieving and sustaining accreditation standards like NABH and JCI etc.

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Maintain Nursing Quality Indicators and various audit information. Monitor trends, identify areas of deviations and recommend remedial actions to the CNO

Key Responsibilities: Finance

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Monitor and ensure optimal utilization of available resources

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Ensure nursing manpower is effectively utilized as per the patient mix, volume and specialties.

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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.

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Ensure the consumables and other materials are utilized judiciously and not causing unwanted consumption

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Ensure the biomedical equipment’s and other instruments of the departments are utilized appropriately without any damages and loss.

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Ensure the Preventive maintenance and functionality of all equipment’s in coordination with biomedical department

Key Responsibilities: People

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Support the DCNO in selection of the most suitable resources for the Quality dept

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Support the Nursing Leadership & HR in selection and onboarding of the most suitable and competent team members

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Set the goals of the team members and drive high performance and professional excellence

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Identify clinical and behavioral developmental needs of the team, and collaborate with the Nurse Educator to create a Training & Development Plan.

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Ensure continuous up gradation and enhancement of functional and technical skills of the team members through implementation of effective professional training / programs.

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Ensure high morale of the team through timely resolution of any grievances / issues

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Co-ordinate with HR and training cell to ensure employees’ complete awareness of the quality system and orientates new employees to the system.

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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

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Provides guidance to the nursing staff, counsels them in quality improvement activities and patient safety programs.

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Initiates & coordinates emergency, patient safety practices and fire safety measures as appropriate.

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Key Responsibilities: Innovations and Research

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Identify and suggest new ideas/ feedback to enhance departmental operations and patient care

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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.

3. Competencies

Competencies

A. Core HNH Competencies

Patient First

Excellence

Accountability

Respect

One Team

Integrity

B. 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

A. Core HNH Values

Patient First

Excellence

Accountability

Respect

One Team

Integrity

B. 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

4. 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:

5. Scope of Work

a) Financial Scope (Range of financial spend):

• NA

b) People Management Scope (Range of no. of Direct Reports):

• Team of Staff Nurses and PCAs

c) Corporate Coverage (hospital-wide / sub-function-wide / area wide):

• Across the Hospital

d) 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

6. 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