Essential Duties and ResponsibilitiesIn this role you will be:
DAILY OPERATIONS- Provides leadership and oversight of the daily operations of Endoscopy, ACU, and Surgical Home.
- Staffing and Scheduling
- Develops and maintains staffing plans based on patient volume, acuity, procedural schedules, operating hours, and organizational needs.
- Oversees daily staffing assignments and ensures appropriate staff are available based on patient care requirements and staff competencies.
- Adjusts staffing based on changes in procedural volume, cancellations, add-on procedures, and patient flow. Monitor productivity, overtime, and staffing-related expenses.
- Promotes appropriate staffing utilization while maintaining safe patient care.
- Collaborates with physicians, anesthesia, procedural areas, and other departments to coordinate daily schedules and optimize patient flow.
- Identifies staffing trends and develops strategies to address recruitment, retention, and workforce needs.
- Department Audits
- Establishes and maintains an audit program for Endoscopy, ACU, and Surgical Home.
- Conducts and/or oversees clinical, operational, regulatory, infection prevention, documentation, and patient safety audits.
- Develops corrective action plans when deficiencies are identified.
- Ensures compliance with organizational policies, regulatory requirements, and applicable professional standards.
- Performance Evaluations
- Completes and/or oversees timely employee performance evaluations.
- Provides ongoing performance feedback and coaching.
- Establishes clear performance expectations and accountability.
- Recognizes employee accomplishments and supports professional development.
- Addresses performance concerns in collaboration with Human Resources and appropriate leadership.
- Orientation and Training
- Oversees orientation and onboarding of new employees by working closely with Professional Development team.
- Develops department-specific orientation plans in collaboration with educators and clinical leadership.
- Ensures new employees receive appropriate clinical, operational, safety, regulatory, and organizational education.
- Identifies ongoing educational needs based on quality data, regulatory changes, new equipment, new procedures, and staff performance.
- Promotes continuing education and professional development.
- Ensures staff are educated regarding changes in policies, procedures, technology, and evidence-based practices.
- Competency Verification
- Establishes and maintains competency validation processes for Endoscopy, ACU, and Surgical Home personnel.
- Ensures initial and ongoing competencies are completed according to organizational requirements.
QUALITY IMPROVEMENT AND PERFORMANCE IMPROVEMENTProvides leadership for quality, safety, regulatory compliance, and performance improvement across Endoscopy, ACU, and Surgical Home.
- Endoscopy Steering Committee
- Coordinates and facilitates the Quarterly Endoscopy Steering Committee.
- Develops agendas, prepares reports, and presents departmental quality and operational data.
- Collaborates with physicians and interdisciplinary stakeholders to identify opportunities for improvement.
- Monthly Updates
- Provides monthly performance updates to leadership and appropriate stakeholders.
- Scorecard
- Develops, maintains, and monitors an Endoscopy/ambulatory services scorecard.
- Tracks key quality, operational, financial, patient experience, and utilization metrics.
- Identifies trends and variances from established targets.
- Communicates results to staff, physicians, and leadership.
- Utilization of Block Time
- Monitors utilization of procedural block time.
- Reviews physician and proceduralist block utilization.
- Identifies unused, underutilized, or inefficiently utilized block time.
- Collaborates with physicians and surgical/procedural leadership to improve utilization.
- Performance Improvement Activities
- Identifies opportunities for performance improvement using quality data, audits, staff feedback, patient feedback, and operational performance.
- Leads or participates in performance improvement projects.
- Promotes a culture of continuous improvement and accountability.
- Scope Washing Monitoring and Competencies
- Provides oversight of scope reprocessing practices in collaboration with Infection Prevention, Sterile Processing, Endoscopy leadership, and appropriate clinical experts.
- Ensures compliance with organizational policies and applicable standards related to endoscope cleaning, disinfection, storage, transportation, and handling.
- Monitors scope washing and reprocessing practices.
- Ensures staff performing scope cleaning and reprocessing maintain required competencies.
- Coordinates initial and ongoing competency validation.
- Identifies deviations from established processes and ensures timely corrective action.
- Monitors documentation associated with scope reprocessing.
- Collaborates with Infection Prevention and other appropriate departments regarding quality or safety concerns.
MATERIALS MANAGEMENTProvides oversight of supplies and materials required for Endoscopy, ACU, and Surgical Home.
- Value Analysis Team/Product Review
- Participates in the Value Analysis Team and product review processes.
- Evaluates new products and supplies in collaboration with physicians, nurses, Supply Chain, Finance, and other stakeholders.
- Reviews products based on quality, safety, clinical effectiveness, standardization, utilization, and cost.
- Coordinates staff and physician input regarding product performance.
- Supports product standardization and cost-effective utilization.
- Supply Inventory and Restocking
- Ensures appropriate levels of procedural, clinical, and patient care supplies are maintained.
- Oversees processes for restocking supplies.
- Monitors supply utilization and identifies opportunities to reduce waste.
- Collaborates with Supply Chain to address shortages, backorders, substitutions, and product concerns.
BUDGET MANAGEMENTProvides financial oversight and accountability for Endoscopy, ACU, and Surgical Home.
- Operating Budget
- Develops and monitors the annual operating budget in collaboration with departmental and organizational leadership.
- Monitors labor, supply, equipment, and other departmental expenses.
- Reviews monthly financial reports.
- Identifies financial trends and opportunities for cost containment.
- Monitors staffing productivity and labor expenses.
- Evaluates supply utilization and cost per procedure when applicable.
- Capital Budget Expenditures
- Identifies capital equipment and technology needs.
- Develops and submits capital requests based on clinical needs, equipment condition, volume, technology, and strategic priorities.
- Provides supporting financial and operational justification for capital requests.
- Budget Variances
- Reviews monthly budget performance and identifies significant variances.
- Communicates significant variances and action plans to leadership.
- Maintains accountability for departmental financial performance.
EQUIPMENT MANAGEMENTProvides oversight of equipment utilized within Endoscopy, ACU, and Surgical Home.
- Lease Agreements
- Monitors equipment lease agreements and associated terms.
- Maintains awareness of lease expiration dates, renewal requirements, and financial obligations.
- Provides recommendations regarding lease renewal, replacement, or alternative equipment solutions.
- Service Agreements
- Monitors equipment service agreements and warranties.
- Tracks service issues and ensures appropriate follow-up.
- Collaborates with Biomedical Engineering and vendors to address equipment failures and service needs.
- Ensures equipment remains operational and available to support patient care.
- Assessment of Current Equipment
- Conducts routine assessments of equipment condition, functionality, utilization, and clinical appropriateness.
- Identifies aging, obsolete, unreliable, or frequently malfunctioning equipment.
- Evaluates equipment needs based on procedural volume, patient safety, technology, and strategic growth.
- Preventive Maintenance
- Monitors compliance with required preventive maintenance schedules.
- Collaborates with Biomedical Engineering and vendors to ensure preventive maintenance is completed.
- Ensures equipment is removed from service when necessary for safety or maintenance.
PATIENT FLOW AND OPERATIONAL EFFICIENCY
- Oversees patient flow across the Endoscopy, ACU, and Surgical Home continuum.
- Identifies opportunities to reduce unnecessary patient wait times and delays.
- Collaborates with proceduralists, anesthesia, nursing, registration, laboratory, radiology, sterile processing, and other departments to optimize patient throughput.
- Establishes standardized workflows for pre-procedure, procedure, recovery, discharge, and follow-up processes.
- Monitors delays, cancellations, and barriers to efficient patient progression.
PATIENT SAFETY AND CLINICAL QUALITY- Promotes a culture of patient safety and accountability.
- Ensures compliance with medication safety, infection prevention, patient identification, procedural verification, and handoff standards.
- Reviews patient safety events, near misses, complaints, and other quality concerns.
- Coordinates appropriate investigation and corrective action.
- Promotes evidence-based clinical practice.
- Collaborates with Quality, Risk Management, Infection Prevention, and other departments to address patient safety concerns.
REGULATORY AND ACCREDITATION READINESS- Maintains readiness for regulatory and accreditation surveys.
- Ensures compliance with applicable federal, state, local, and organizational requirements.
- Monitors compliance with policies and procedures.
- Coordinates preparation for regulatory and accreditation reviews.
- Ensures required documentation, audits, competencies, and performance improvement activities are maintained.
- Responds to identified deficiencies and ensures corrective actions are implemented and sustained.
STAFF LEADERSHIP AND DEVELOPMENT- Creates an environment that promotes teamwork, accountability, engagement, and professional growth.
- Establishes clear expectations for clinical and professional performance.
- Provides coaching, mentoring, and ongoing feedback.
- Promotes employee recognition and engagement.
- Supports recruitment and retention strategies.
- Identifies opportunities to develop staff leadership capabilities.
- Addresses employee concerns and facilitates conflict resolution.
PHYSICIAN AND INTERDISCIPLINARY COLLABORATION- Establishes and maintains effective relationships with physicians and proceduralists.
- Collaborates with the Endoscopy Steering Committee and physician leadership regarding quality, utilization, access, and growth.
- Communicates operational concerns and opportunities to appropriate providers and leadership.
- Supports physician engagement in quality and performance improvement initiatives.
QUALIFICATIONSRequired:
- EDUCATION:
- Bachelor's degree in nursing required, master's degree n Nursing, Healthcare Administration, Business Administration, or related field preferred
- EXPERIENCE:
- Minimum of 3-5 years of progressive clinical experience.
- Previous management, supervisory, coordinator, or charge nurse experience preferred.
- Experience in Endoscopy, Perioperative Services, Ambulatory Care, Surgical Services, or a related procedural environment preferred.
- LICENSURE/CERTIFICATION:
- Current license as a Registered Nurse in Pennsylvania.
- BLS certification required
- Additional specialty certification related to perioperative, endoscopy, ambulatory care, or leadership preferred.
