1. Works collaboratively with members of the CareTeam to ensure that patients receive skilled
nursing care that meets their individual needs. This will be measured by Picker results.
a. Assesses patients' needs, plans care and coordinates appropriate assignments for team
members 100% of the time.
b. Participates in team meetings.
c. Establishes relationships with staff that promote a professional and productive work
d. Evaluates and documents outcomes of patient care. Actively participates in quality
e. Communicates with other team members regarding patients.
f. Serves as a resource for difficult or complex situations. Refers appropriate problems to
g. Participates in presenting education programs to team members to ensure competence.
h. Works with team members to monitor patient satisfaction and develop appropriate
i. Administers medication according to nursing/hospital/unit policy/procedure without errors
100% of the time.
2. Provides direct patient care as a member of the CareTeam.
a. Provides and documents competent nursing care based on scientific principles and uses the
nursing process and meets policy.
b. Administers medications according to nursing, hospital, unit policy and procedures and
meets outcome measures.
3. Education is planned and provided according to care plan and predicted Length of Stay for
every patient who is alert and able to comprehend. Family members and care givers are included
in education as appropriate.
a. Participates in the development of educational materials/presentations for patients and/or
significant others and documents outcome in the medical record.
b. Ensures that patients and significant others receive education regarding discharge and the
community services available.
4. Works with the CareTeam members to manage the patient's stay in the hospital based on
anticipated length of stay. Every patient has a targeted length of stay and a care plan that
reflects that target.
a. Works with team to plan care according to anticipated Length of Stay, clinical path and/or
b. Collaborates with nurse coordinator, case managers, physicians and other departments to
ensure appropriate LOS and discharge planning.
c. Coordinates timely completion of procedures, tests and consults during hospital stay.
d. Communicates clinical information to appropriate parties.
e. Collaborates with team members to plan for improvements regarding patient care.
f. Monitors LOS for observation patients and collaborates with nurse coordinators and case
managers to ensure appropriate stay.
g. Discharge planning begins day one for all patients. Family members are included in this
h. All patients returning home receive a written discharge or instruction plan prior to
discharge 100% of the time.
1. Knowledge of nursing process, theories, and clinical expertise related to patient care,
normally acquired through the completion of a nursing training program at an NLN accredited
school of nursing.
2. Current registration in the Commonwealth of Massachusetts.
3. Interpersonal skills to interact with patients, families, and a multidisciplinary team of
health-care personnel to resolve complex problems.
4. Able to acquire through training programs and continuing education technical knowledge
related to assigned area.