JOB SUMMARY: The Associate CNO is responsible for the assistance of the day to day operations of the hospital and clinical units. The ACNO works with the Chief Nursing Officer, Administrative team members and department heads to ensure compliance with goals and objectives established by the hospital. The ACNO oversees the following departments: Nursing Administration, Infection Prevention, Employee Health, Quality/Risk, Regulatory Affairs and Patient Care Departments as assigned. Responsible for various initiatives including but not limited to Value Based Purchasing, Hospital Acquired Conditions program, Lean Initiatives, various Patient Experience processes and surveys. Understands the priority items of the Nursing Vision. Works collaboratively with the team as the co-owners for survey preparation. Focus for Risk management is ongoing, comprehensive & systematic approach to reducing risk exposure of the organization. Proactively implementing provisions of federal, state, and local statutes, rules & regulations. This is accomplished by collaboration with all departments, reviewing risk reports, coordination with Corporate Risk, when necessary. Works collaboratively to assure that SMC has an effective Infection Control program. Assures appropriate reporting of infection data to designated sources such as CDC, NHSN, etc. Communicate effectively, in writing, verbally, and via telephone, with all levels of personnel and visitors. Input and retrieve computerized data.

PERFORMANCE ACCOUNTABILITY

A. KNOWLEDGE OF WORK

1. Demonstrates knowledge of hospital operations and Policies & Procedures.
2. Familiar with Administrative policies and procedures.
3. Fully aware of the company’s confidentiality policy and fully complies with it. Demonstrates respect for privileged and confidential information.
4. Knowledgeable with proper office procedures and ensures an efficient and effective office environment.
5. Demonstrates fully functional filing systems for different projects, e.g. Contracts, Regulations, TJC/CDPH/CMS, etc.

B. DUTIES AND RESPONSIBILITIES
1. Ensures the effective and efficient management of nursing department operations.
2. Assists the CNO with patients’, physicians’, employees’ concerns or issues as they relate to hospital operations. Ensure the follow-through of the issues being delegated to appropriate personnel.
3. Efficiently and effectively takes minutes for department management meetings and other meetings as assigned. Assists in the preparation, planning and execution of agenda.
4. Ensures compliance with title 22 and other regulations for staffing, patient classification systems, and other nursing administration department functions including contract labor compliance, dialysis, wound care services, etc.
5. Works with appropriate directors, Quality and education to ensure compliance with standardized procedure requirements for RNs.
6. As directed, follows up with unresolved situations to gather information, etc.
7. Performs other duties as assigned or required.
8. Ensures compliance with regulatory standards and reporting requirements (i.e. CDPH, Federal/State regs, Never 28, etc.).
 Assures that effective event/incident/reporting system is in place with effective followup. System must identify issues, report, track and trend events. Maintains system for tracking and trending of hospital occurrences. Reports trending to Quality Council, MEC and Governing Board.
 Events are tracked/trended and reported to appropriate departments for action/follow-up, trending reports provided by department with action to correct trends. Facility dashboard presented to governing board.
 Mitigate incidents and implements revised processes to reduce facility risk. Collaborates with corporate risk and facility carrier to mitigate issues/risk.
 Investigates and follows up on complaints/concerns/ grievances. Reports findings to CNO and collaborates on response. Notifies CNO immediately upon discovery of any identified or potential Sentinel Event.
 Provides educational activities for staff. Conducts general orientation
 Maintains Patient Complaint/Grievence log. Trends and reports data as necessary, to appropriate committees.
 Works collaboratively with Corp RM for Claims management including; reporting events, investigation/interview, protecting documents, managing claims, coordinating depositions,, assisting defense team, forwarding subpoenas & summons.
 Completes and submits annual RM summary and plan to the governing board.

 Apply epidemiologic principles and statistical methods, including risk stratification, to identify target population, analyze trends and risk factors, and design and evaluate prevention and control strategies.
 Conduct on-going surveillance using Center of Disease Control (CDC) infection criteria, documentation, and investigation of nosocomial infections through review of admission diagnoses, microbiology culture results, isolation orders, patient records, consultation requests, post-discharge surveillance, and autopsy findings.
 Responsible for NHSN data accuracy and ensuring deadlines are met.
 Works collaboratively with Perioperative, Perinatal, SPD and other applicable areas to ensure appropriate processes are in place for patient safety and infection control compliance.
 Assess environmental control through surveillance of water supply systems as needed, air pressure relationships for high risk environmental monitoring.
 Conduct environmental rounds in all inpatient and outpatient care areas. Collect data on the incidence of selected device use in identified intensive care units.
 Participate in investigations of unusual hospital infection outbreaks utilizing the microbiology laboratory, consultation with Infectious Disease Division, county/state public health departments, and when necessary in consultation with the Center for Disease Control. Report epidemiologically significant findings to appropriate customers.
 Evaluate the effectiveness of the surveillance plan and modifies as necessary.
 Report all in-house patients with communicable disease to the county and/or state health department and maintain appropriate records. Compile and interpret surveillance reports to Infection Control committee, specialty areas, and executive medical committee on a regular basis.
 Collaborates with the CNO and directs and participates in the preparation and administration of nursing services, budgets and capital outlay requests; evaluates staffing, equipment and supply needs; prepares justifications and cost benefit analyses; reviews and recommends approval of expenditures; oversees the procurement of supplies and equipment for assigned areas.
 Ensures development of subordinates and succession planning.

C. INITIATIVE AND JUDGMENT/ATTENDANCE AND RELIABILITY
1. Independently recognizes and performs duties which need to be done without being directly assigned. Establishes priorities; organizes work and time to meet them.
2. Recognizes and responds to priorities, accepts changes and new ideas. Has insight into problems and the ability to develop workable alternatives.
3. Accepts constructive criticism in a positive manner.
4. Adheres to attendance and punctuality requirements per hospital policy. Provides proper notification for absences and tardiness. Takes corrective action to prevent recurring absences or tardiness.
5. Uses time effectively and constructively. Does not abuse supplies, equipment, and service.
6. Observes all hospital and departmental policies governing conduct while at work (e.g., telephone and computer use, electronic messaging, smoking regulations, parking, breaks and other related policies).

SECTION II: SERVICE EXCELLENCE
1. Understand, respects and displays sensitivity to culture, age and persons with disabilities.
2. Participates actively and positively affects the outcomes of customer service activities.
3. Uses effective collaborative strategies as evidenced by:
a) Developing peer relationships that enable the work group to accomplish the daily workload within the allotted time frame and achieve departmental goals.
b) Recognizing and understanding that as a member of an interdependent group, collaboration and compromise is required in order to maintain the effectiveness of the group as a whole to effectively resolve problems.
c) Timely notification to Department Manager/Director of potential problems or concerns. When faced with a problem or concern, is proactive by presenting suggested solutions at the time that the Department Manager/Director is made aware of the problem or concern.
d) Displaying teamwork ability to promote cooperation and collaboration; gaining support for programs and goals.
e) Supports Patient Rights.
4. Displays honesty and respect for others, and respect for the organization as evidenced by:
a) Treating internal and external customers as the most important part of the job.
b) Being sensitive to customer’s emotions, thoughts and feelings.
c) Refraining from negative comments of any kind where the public or other customers can hear.
d) Taking appropriate actions to resolve the concern.
5. Facilitates and enhances communication as evidenced by:
a) Effective and timely processing of customer’s requests according to hospital and departmental policies.
b) Utilizing verbal communication methods, which enable others to clearly understand what is being said.
c) Utilizing verbal and non-verbal behaviors without being defensive, manipulative, aggressive or controlling.
d) Using written communication that is legible, timely and at a level based on the position specific requirements.
e) Listening attentively to ensure effective two-way communication.
f) Expressing and accepting feedback in a professional manner.
g) Answering the telephone with stating department, name and greeting.
6. Interacts with coworkers, other hospital staff, physicians, and the public in a courteous, professional and efficient manner.
7. Establishes good rapport and working relationships with coworkers, other hospital staff, physicians and the public.
8. Observes dress code policy and wears hospital identification as required by our policies and procedures.

SECTION III: CONTINUOUS QUALITY IMPROVEMENT

A. CORPORATE INTEGRITY
1. Understands and abides by all departmental policies and procedures as well as the Codes of Ethics, HIPAA requirements and patient rights.
2. Complies with Federal, State, Local Laws that govern business practices. Complies with all Department of Health Services requirements for the State of California, and CMS standards that apply to the position.
3. Is knowledgeable and adheres to TJC/CDPH/CMS standards specific to the position.
4. Participates actively in ensuring that all State and Federal Rules and Regulations are followed as they apply to this position.
5. Conducts business in an ethical and trustworthy manner at all times when dealing with patients, visitors, physicians, and fellow employees.

B. EDUCATION AND ENVIRONMENT OF CARE
1. Attends scheduled inservice and mandatory inservice. Communicates ideas to supervisor for a safer layout of equipment, tools, and/or processes.
2. Follows standard precautions and transmission based precautions as shown by consistent use of appropriate personal protective equipment.
3. Adheres to procedures for the disposal of waste – household waste and biohazard waste as well as the proper disposal of sharps.
4. Uses proper body mechanics at all times. Seeks assistance when necessary to move heavy objects or to transport/transfer a heavy patient.
5. Is knowledgeable in the hospital safety program and takes necessary steps to maintain a safe environment. Adheres to safe work practices in order to prevent injuries and illnesses.
6. Is familiar with emergency codes and emergency preparedness procedures and understands his/her role in response to each of the emergency codes (Code Blue, Code Pink, Code Orange, Code Yellow, Code Gray, Code Silver, Code Purple, etc.)
7. Maintains the department in a neat, clean, and orderly manner, especially in own work area.
8. Eliminates or assists in eliminating any seen or known hazards in the workplace. Reports any unsafe conditions to his or her immediate supervisor.
9. Demonstrates good safety habits and judgment by maintaining a safe environment at all times.
10. Complies with all hospital safety and injury prevention policies and regulations.

C. PERFORMANCE IMPROVEMENT
1. Understands the Continuous Quality Improvement Process and applies it in performing everyday tasks/duties. Active participant in Continuous Quality Improvement program by assisting in finding new and better ways of performing duties and responsibilities.
2. Cooperates with others in the improvement of services offered at our institution. Continually makes recommendations that assist in the improvement of services.
3. Continually strives for self-improvement in areas of responsibility by attending continuing education classes.

EDUCATION, EXPERIENCE, TRAINING
1. Proficient with computer software (Word, Excel, Power-Point, etc.)
2. Must have a current and valid license as a Registered Nurse issued by the State of California.
3. BLS Provider Card, upon hire and maintained current.

4. Minimum of 5 years Acute Care experience.
5. Minimum of 3 years previous Administrative experience preferred.
6. Master’s Degree in Nursing is preferred but a BSN is required.

7. ACLS Provider card thru AHA

8. NIHSS required