Clinical Director

PERFORMANCE STANDARDS
Standard
No. Weight
1.0 1.1 35% CLINICAL ACTIVITIES
Provides support and resources to the Clinical Staff to ensure that quality patient care is delivered by:
 Monitor staffs credentials
 Performs annual skill validations
 Uses surveillance technique for ongoing skill validation
 Maintains enforcement of all clinical Policies & Procedures (P&P)
 Maintains enforcement of AORN standards
 Understanding of the principles of sterile technique and operating room practices.

1.2 5% Participate in patient care activities and adheres to requirements of Registered Nurse position description when providing direct patient care. Demonstrated by:
 Assuring appropriate patients are admitted following established patient selection criteria as per the Centers P&P.
 Ensuring patients receive explanation of procedures when they arrive and ensure the patient prior to administration of anesthesia signs appropriate surgical consents.
 Reviewing and assuring appropriate surgery procedures are admitted to facility based on the approved procedures list.
 Accurately transcribing orders and documents patient care, including discharge directives.

2.0 20% QUALITY IMPROVEMENT ACTIVITIES
Ensures that the Center achieves quality patient care by utilizing ongoing quality improvement, safety and infection control evaluation methods such as review of the medical record, analysis of medication errors and patient injuries and review of infection control responses from physicians and patient satisfaction questionnaires. Demonstrated by:
 Maintain a Quality improvement Program with quarterly meetings and report as appropriately to Administration.
 Implement Quality Improvement projects as per AAAHC standards.
 Reporting to Quality improvement Committee & Governing Board on status and follow-up 100% of time with recommendations.
 Reviewing infection control data and maintain an infection rate of less than 1%.
 Maintain an Infection Prevention Committee with regular meetings.
 Perform Peer Review on Nurses monthly and Surgeons/Anesthesia quarterly.
 Benchmark with National Associations and other like facilities.

Standard
No Weight
CUSTOMER SERVICE
3.0 10% Maintains active professional relationships with doctors, staff and patients by assessing needs and levels of satisfaction. Demonstrates a positive, friendly and courteous manner. Identifies, measures and documents or reviews problems, inefficiencies or deficiencies as shown by:
 Positive Patient Satisfaction Survey scores.
 Positive patient Outcomes.
 Positive Physician Satisfaction Survey Scopes.
 Positive Employee Satisfaction Scores.
 Develops and maintain an effective working relationship with patients, families, visitors, medical staff members and Center employees.
 Responding to negative responses within three business days or refers to Administration.
 Documenting valid service deficiencies in employee files and maintains records.
 Preparing recommendations to resolve deficiencies.

Standard
No. Weight
4.0 10% EMPLOYEE MANAGEMENT
4.1 5% Demonstrates ability to delegate and/or supervise, orient, hire, develop, train, coach, evaluate, discipline and terminate nursing staff as evidenced by:
 Interviewing candidates and offers positions.
 Assisting in the orientation and training of new employees or employees who are new to their position.
 Employing active listening/listens with full attention when communicating with staff, physicians and Administration.
 Appropriately assigns and delegates tasks.
 Responsible for recruiting, hiring, staff retention, performance evaluation and staff development.

4.2 5% Performs staff performance appraisals of direct reports as required by policy. Maintains accurate employee files and achieves positive working environment by:
 Effectively communicates job performance criteria and expectations and provides appropriate feedback regarding performance.
 Evaluating job performance on 90-day or annual basis with 80 to 85% employee performance appraisals completed within 14 days of employee anniversary date.
 Following through with appropriate disciplinary action when required as defined by policy.
 Annually hold employee opinion survey and address any negative issues.
 Consistently demonstrating dependability and teamwork skills with positive attitude and sets example for nursing staff.
 Maintaining confidentiality of information to which is privileged.

5.0 5% RESOURCE AND INVENTORY MANAGEMENT
Ensures that resources and education are provided to the Clinical Manager to help ensure positive financial outcomes for the Center as evidenced by:
 Coordinates appropriate use of human, financial and material resources being mindful of budgetary constraints.
 Ensures cost-conscious use of all resources

6.0 10% REGULATORY COMPLIANCE
Complies with State, Federal, local and accreditation rules, regulations and/or guidelines and assures nursing staff compliance by:
 Attainment of State licensure
 Attainment of Medicare Certification
 Attainment of AAAHC accreditation
 100% of regulatory concerns or unusual occurrences are reported to Administration within 24 hours of discovery.
 Reviews and updates policies and procedures, risk management and safety guidelines, and Center's position descriptions for compliance with Federal and State legislation, accreditation standards, and good performance management practices.
7.0 5% SAFETY
Ensures that Center in maintained in safe condition as indicated by compliance with the Life Safety/Hazard Surveillance monitor results. Adheres to all facility safety regulations and guidelines regarding patient safety as evidenced by:
 Identifies, corrects or reports unsafe conditions immediately.
 When patient injury/disaster occurs, Administration notified immediately.
_____
100%

QUALIFICATIONS

Skills, Knowledge and Abilities:
Knowledge and experience in hospital, operating room or ambulatory surgery center nursing care (direct patient care). Effective communication skills: oral, written, and presentation. Ability to set one's own schedule and manage own time. Ability to effectively manage the activities and personnel of nursing. Knowledge of current matters relating to healthcare management including Quality improvement fundamentals and activities. Ability to utilize resources in an organized manner. Effective positive interpersonal and customer relations skills via telephone and face-to-face interaction.

Education/Experience:
Education/credentials as Registered Nurse and at least five years of clinical experience, two of which were in nursing administration/OR management within last five years. Experience as registered nurse in at least one of the following areas: recovery room (PACU), post-surgical, medical-surgical, emergency room, intensive care or operating room. Current Registered Nurse license required. Current CPR and ACLS certification required. A Bachelor of Science in Nursing preferred.

License/Certification Required:
RN license in state Center located required.
CPR Certification required.
ACLS Certification required or Specialty Certification

Physical Requirements:
 Capable of heavy work with walking and frequent lifting of 50 lbs. associated with occasional lifting of patients and/or carrying up to 15 lbs.
 Spends 60-70% of time walking, standing or sitting while working with patients.
 Walks approximately 5 hours per day or more through facility, frequently standing, bending, stooping and reaching to check or move equipment and assist patients and staff.
 Spends 30-40% of time at desk, or participating in meetings.
 Must be able to speak and hear clearly.
 Must be able to write and record numbers in fine detail, transcribe physician orders, and complete annual evaluations, accurately read labels and instructions.
 Must be able to key at computer terminal and have basic computer skills.
 Ability to perform CPR.
 Ability to organize multiple tasks daily and reprioritize tasks.

 Accommodate occasional frustration and anger on part of patients, families and physicians and fellow nursing staff.