K.     NURSING PERSONNEL: SELECTION, RETENTION, DEVELOPMENT, EVALUATION, AND CREDENTIALING

9.  JOB DESCRIPTION/PERFORMANCE APPRAISAL DEVELOPMENT

1. All Job Descriptions and Performance Appraisals used by Clinical Programs are Competency Based Tools

• RN’s, LPN, Unlicensed Patient Care Providers Inpatient, Outpatient, ACRC
• Scope of Practice Committee oversees the development and implementation of job descriptions.
• The Scope of Practice Committee has interdisciplinary representation and is part of the Professional Nursing Organization.
• See attached for complete description of Scope of Practice bylaws and structure (Addendum E.1).
• Job Descriptions and Performance Appraisals are reviewed annually and necessary competencies added.
• Human Resources serves in a consultative capacity in the development of job descriptions and performance based criteria.
• Some job descriptions are classified and format is dictated by the State of Arkansas.

b.   RN's and LPN's - Support Departments (Radiology, Laboratory, Patient Coordination, and Clinical Programs Education Department)

• Departments use a multidisciplinary process with input from staff, other departments, management, and Human Resources in the development of Job Descriptions and Performance Appraisals.
• Job Descriptions and Performance Appraisals are reviewed annually and necessary competencies added.
• Human Resources serves in a consultative capacity in the development of job descriptions and performance based criteria.
• Some job descriptions are classified and format is dictated by the State of Arkansas.

L.   NURSING QUALITY ASSESSMENT AND IMPROVEMENT PROCESS INPATIENT AND OUTPATIENT

1. Nursing will participate in multidisciplinary quality improvement activities through the Clinical Programs’ Performance Improvement Plan. When an interdepartmental process is identified for improvement, Nursing members will participate in the chartered CQI teams. Addendum L.1

2. The Practice Improvement Council will review results of the monitoring and evaluation process at monthly meetings. Reports will be taken to the Executive Council meetings by the Practice Improvement Council Chair monthly. Quarterly reports of the Nursing monitoring and evaluation activities will be sent to Quality Management Department by the Nursing Quality Improvement Manager.  Addendum E.1h

3. The Practice Improvement Council will review results of the monitoring and evaluation process at monthly meetings. Reports will be taken to the Executive Council meetings by the Practice Improvement Council Chair monthly. Quarterly reports of the Nursing monitoring and evaluation activities will be sent to Quality Management Department by the Nursing Quality Improvement Manager.

4. Sentinel events will be reported directly to the Hospital Risk Manager and the Personnel Management Council for the peer review process. Trends or patterns relating to the processes of nursing care will be monitored by the Practice Improvement Council at the request of the Personnel Management Council.  Significant/Sentinel Events ML.1.09

5. Risk Management indicators reported through the Patient Safety Net, PSN, report process will be monitored in an ongoing, systematic process. PSN reports from inpatient nursing units will be sent directly to the Risk Management office for review. These reports will be forwarded to the Director of Quality Programs and appropriate Clinical Services Manager.  Following the review of the issues, the PSN reports will be forwarded to Quality Management Department for inclusion in the quarterly variance reports. Patient And Visitor Variance Reporting ML.1.04

Back to Policy Standards Table of Contents
Home