Chief Nursing Officer

Chief Nursing Officer/Quality Compliance 

Job Summary:

Responsible for overall assessment, implementation of treatment, and evaluation of quality clinical services for patients and directing quality management efforts to ensure continuous improvement and organizational excellence, adherence with all regulatory, compliance, accreditation, and legal issues, and promote a safe environment for all employees, patients and visitors.  This position has oversight of all clinical staff, a multi-disciplinary professional team. Develops hospital-wide systems, policies and procedures designed to meet the patient care need.  Responsible for planning for the appropriate utilization of resources, maintaining or improving the work environment, and monitoring and improving the quality and appropriateness of care. Works closely with Physicians to address patient care needs and enhance patient care systems.  Has overall responsibility and accountability for the development of staffing plans and development and implementation of departmental budgets. Is accountable for the development, management and coordination of the Hospital-Wide Performance Improvement Program.  Responsible for maintaining compliance with CMS Conditions of Participation, The Joint Commission standards, COLA/CLIA standards and HIPAA Rules and Regulations.    This position has clinical authority over the infection prevention and control program, and ensures compliance requirements are met, adheres to program guidelines, and develop, manages and monitors programs.  Responsible for conducting proper training among staff for delivering superior patient care, monitoring potential infection control issues and investigates known or suspected sources of infections, and monitors for compliance with established standards.  Develops and provides related education to staff. Complies with state, federal and Joint Commission standards relating to infection control. Promotes the facility through active involvement and participation in external and internal activities concerning health care services

Position Qualifications:

• • Master of Science in Nursing, preferred.
  • Bachelor of Science in Nursing required.
  • Four (4) years of Psychiatric hospital nursing experience, preferred.
  • Experience, or equivalent, in quality/risk management activities, preferred.
  • Familiar with CMS, The Joint Commission, and State Regulations
  • Experience in Infection Control, preferred.
  • Experience in Patient Advocacy, preferred.
  • Previous experience with regulatory body surveys/inspections 

Supervisory Responsibility:

Supervises the following positions:

Manages and directs clinical departments, which may include, nursing and Staff Education / Development.

Key Responsibilities / Job Accountabilities:

• Ensure staffing of clinical positions and participate in recruiting, corrective actions, termination, etc.
• Ensure staff competency
• Be a resource for explaining mental health laws and regulations to staff and leadership.
• Responsible to plan, organize, direct, and evaluate the work of nursing and support staff specific to patient care and always strive to improve to be better.
• Evaluate, observe and assess the emotional and physical need for mental health services among patients.
  
• Establish and maintain working relationships with other mental health professionals, subordinate staff, and co-workers.

• Direct, plan, develop and implement quality management efforts for the hospital. Oversees the hospital wide performance improvement program (QAPI) including infection control, advises and assists department managers in their efforts to monitor, evaluate and correct their programs relative to the applicable standards, oversee performance improvement team activities and facilitate as appropriate.
• Oversight of quality of patient care utilizing accreditation, licensure, and regulatory standards.
• Advised department managers in the area of policy and procedure development relative to the applicable standards.
• Serve as coordinator for surveys, investigations, regulatory changes and updates.                                                                                  
  

• Assures completion and tracks new hire Employee Health completion
• Assures completion and tracks new hire competency and annual competency
• Provides oversight to the FPPE/OPPE process for the medical staff credentialing for the facility.
• Monitors risk management activities and acts as a resource to hospital.
  
• Plan, develop, maintain, promote, implement, and evaluate for all employees
  
• Educational record system
• Mandatory competency requirements
  
• Immunization record system
• Infection Control Program
• Support and ongoing education of all team members
• Identify and monitor specified nosocomial infections
• Makes rounds of hospital units to monitoring infection control practices
• Develop policies and procedures to insure educational and rigorous infection control standards that meet Joint Commission, OSHA, Ohio Department of Mental Health and Addiction Services, Center for Disease Control requirements, and other regulatory organizations.
• Foster an environment that supports the utilization of evidence-based practice and clinical research.

Additional Skills / Qualifications:

• Conduct learning needs assessments
• Participate in the development and review of best practice guidelines
• Participate in quality improvement activities and organizational accreditation processes
• Participate in relevant committees, councils, and other activities, as appropriate
• Participates in performance improvement projects
• Assists in planning, with hospital leadership and other personnel, to reduce the risk of disease transmission and improve infection control practices.
• Assist leadership in developing educational programs to support individual learning plans
• Perform assessments of individual team members, as requested by leadership
• Educate employees about infection control and job specific competencies
• Assists with education and training for all employees for all programs required by regulatory bodies.
  
• Serves as Patient Advocate. Oversees collection and reporting of patient satisfaction data.
• Chairs Quality meetings and communicates quality indicators, issues and concerns with leadership.
• Attend and participate in facility meetings.
• Knowledge of emergency and disaster procedures of the facility.
• Participate in hospital wide safety program identifying risks to patient safety and reducing healthcare errors.
• Participates in relevant in-service training sessions.

CERTIFICATES, LICENSURES, REGISTRATIONS:

Current, valid, and active license to practice as a Registered Nurse in the state of employment required. Current BLS certification required.

Benefits:

Medical

Dental

Vision

401 (k)

Generous PTO and Holiday package