Nursing Excellence Specialist-Nursing Quality
Job Description
This role is responsible for the coordination of all activities related to Nursing Excellence that includes maintenance of clinical integrity and regulatory compliance, the National Database for Nursing Quality Indicators (NDNQI), Magnet and Joint commission accreditation/reaccreditation, and DOH related monitoring.
The role may also involve data collection/monitoring of measures identified by Nurse Leaders as a priority to identify improvement opportunities.
Responsibilities
Audit, Performance Improvement, Accreditation, and Training:
• Promotes the culture of Nursing Excellence, utilizing Magnet principles.
• Assists in Joint commission and Magnet preparedness, accreditation and re-accreditation.
• Collaborates with nursing leadership in ensuring staff adheres to the organization’s internal policies/standards.
• Assists with audits for clinical oversight that evaluates the adherence of compliance to the standards of nursing practice.
• Ensures provision of a clean and safe work environment that minimizes risks to patients, visitors, other staff, and self. Identifies faulty and defective equipment and furniture, removes from service, and takes corrective action.
• Monitors staff performance, providing regular constructive feedback, coaching, guidance, and support to team members.
• Identifies gaps in nursing practice that are addressed through the review of standards, current evidence, review of policy for consistency of content with practice, and communicates training needs in conjunction with the Clinical Resource Nurse and Manager to the professional development team for staff training as well as follow-up.
• Reviews Nurse Sensitive Indicators (NSIs), Zero Harm, RN satisfaction/engagement , and Patient Experience/Satisfaction data to trend results to provide guidance to the Unit Based Practice Councils (UBPCs) and unit’s/department’s leaders on how to develop improvement initiatives.
• Provides guidance in the process of development of action plans with the nursing leader(s).
• Supports the implementation and development of quality strategies to solve care system deficiencies and evaluates their effectiveness.
• Develops and implements quality strategies to solve care system deficiencies and evaluates their effectiveness.
• Responds to all levels of emergencies according to the organization’s policies and procedures
• Monitors and evaluates unit results in order to identify problems and takes a lead role in improving systems and safe patient care
• Participates as a leader or co-leader or member in interdisciplinary teams and Performance Improvement Projects for evaluation and improvement of processes and clinical practice.
• Provides support and mentorship to nursing staff during the Performance Improvement Projects.
• Provides awareness and education to all/relevant nursing staff on the Nurse Sensitive measures.
• Delegates to the nursing team in response to an emergency.
Data Management:
• Develops an annual data collection plan in line with Nursing Department Strategy.
• Maintains the Nursing Department database for the selected unit and /or specialty-specific indicators.
• Provides tracked, trended and actionable data in a timely manner and creates mechanism to make data available to SSMC Nurse Leaders and Managers as appropriate.
• Acts as the primary point of contact between NDNQI and Sheikh Shakhbout Medical City, including the of the NDNQI site coordinator and RN satisfaction survey coordinator.
• Shares, disseminates and utilizes information and resources from the NDNQI website to ensure staying up to date with NDNQI requirements and recommendations.
• Ensures maintaining the security of the NDNQI website, this includes granting site access, tutorial permissions, and changing roles.
• Works collaboratively with Material Management, Legal Affairs, and Nursing to ensure the validity of NDNQI contract with Press Ganey and alerts relevant stakeholders of the expiry date.
• Collects/supervises accurate data collection and submission, ensuring that all data submitted conforms to NDNQI reporting requirements.
• Analyzes/interprets and disseminates NDNQI results and reports on timely manner.
• Develops and/or facilitates the development of action plans for measures not meeting the selected benchmark.
• Uses data to identify improvement opportunities and works collaboratively with members of the multidisciplinary team.
• Works collaboratively with nursing units to identify the unit and/or specialty-specific indicators, other than NDNQI, and facilitates monitoring, reporting, data analysis, action plan and performance improvement.
Accountabilities
• Responds to all levels of emergencies according to the organization’s policies and procedures.
• Provides comprehensive reports related to unit/departmental results/reports as required.
• Completes appropriate documentation according to organization policy.
• Monitors unit and departmental results and if variances are identified, initiates corrective measures as required.
• Promotes and audits compliance with the organization’s Infection Control policies.
• Monitors and audits compliance with organization documentation standards.
• Reports Adverse Drug Reactions (ADRs) and Medication errors in accordance with organization policy.
• Identifies, investigates, reports, and implements corrective action for incidents or complaints as appropriate.
• Demonstrates evidence of mandatory and unit-specific competencies completion, accredited and non-accredited Continuing Nursing Education (CNE) Units DOH and organization requirements, and ongoing professional development in leadership and management.
• Maintains own Professional Portfolio as per DOH policy.
• Maintains ongoing clinical knowledge through internal/external training programs, provides interpretation of knowledge and direction to staff.
Qualifications
Experience :-
Required:
• 6 years’ experience post qualification in a relevant setting
• NLT 2 years’ experience as Nursing excellence specialist / NDNQI site coordinator or co-site coordinator
Desired:
• Experience in a Magnet or Pathway to Excellence hospital
• Lead quality improvement projects/initiatives at department level
Educational Qualification: Required:
• Bachelor of Science degree in nursing
• Valid/current national license
• BLS
Desired:
• MSc in nursing / Quality / Healthcare / management or administration field
