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System Wide Employee
General Standards
Date Prepared:
Finalized: October 17, 2008
Name:
Department #:
Title: Head Nurse
Reports to: Clinical Director or Administrative House Supervisor
Job Code: 300
Grade:
Patient-Age Populations Served: all patients
Education: BSN
Experience/Qualifications: Requires knowledge of organization and operation of a patient care unit and knowledge of nursing care
techniques and methods generally acquired through three to five years of experience as a professional nurse with progressively more
responsible Charge Nurse experience in appropriate specialty area. Current RN licensure with South Carolina Board of Nursing.
BLS and ACLS preferred..
Special Skills: Works with patients, families, staff nurses, physicians, and other health care providers.
Other:
American Heart Association Healthcare provider course with Basic Life Support (BLS) certification required to be initially completed with the GHS Staff Development
Office within 30 calendar days of hire date (exceptions to obtain certification from a provider other than the GHS Staff Development Office are approved by Staff
development on a case by case basis). BLS Recertification is required every two years.
Physical Requirements: Medium While performing the duties of this job, the employee is frequently (activity or condition exists from 1/3 to
2/3 of the time) required to stand, sit, and walk; occasionally (activity or condition exists up to 1/3 of the time) to use hands, fingers; and
frequently to talk or hear. The employee must exert 20 to 35 pounds of force occasionally, and/or 10 to 15 pounds of force frequently,
and/or greater than negligible up to 10 pounds of force constantly to move objects.
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential
functions of this job.
May be exposed to infectious specimens, diseases, and soiled laundry, however, potential for personal harm or injury is limited when proper
safety and health precautions are followed.
Position Summary: The Head Nurse is responsible for the provision of nursing care based on standards of care and professional
nursing practice; accountable for the outcomes of nursing care delivered.
Threshold Requirements. (NOTE: Employees will forfeit performance
pay by “one-half” should he/she fail to meet “all” the “Threshold
Requirements”. Please refer to the Performance Appraisal User’s Guide for
further clarification.)
1.
2.
3.
Has met/meets all requirements
Completed the annual System mandatory education requirements
(i.e.: Health Stream).
Complied with Tuberculosis Surveillance Program
Ensured active and current professional licensing and/or
certification(s) throughout entire performance review year.
4.
5.
6.
Completed all Customer Service classes within 12 months of hire
date. (Current employees will have completed all Customer Service
classes prior to annual performance appraisal.)
Completed all assigned competencies
Attended all classes of orientation
1
Has not met/does not meet requirements
Category
Please refer to the Performance Appraisal
User’s Guide prior to scoring any general
standard
Value
I. Performance Appraisal General Standards
Exceeded
Met
Not
Met
Key: Exceeded x 2, Met x 1, Not Met = 0
1. Communication and Interactions 29
1.1. Attended monthly department meetings
1.2. Demonstrated conflict resolution skills with manager, peers and others
1.3. Actively participated in annual Performance Appraisal process
1.4. Adjusted communication style and language according to “population specific”
related needs of patients, family members and others
1.5 Used professional language in all written and oral communication
1.6 Activated the proper chain of command to resolve any situation that the employee
cannot resolve
1.7 Promoted personal and professional growth through educational opportunities e.g.
coaching, mentoring, and precepting.
2. Cost Effectiveness and Awareness 8
2.1. Utilized supplies in a cost effective manner to include charge capture
2.2. Utilized proper equipment according to manufacturer’s instructions
2.3. Utilized time effectively to complete assignments
3. System Policy Compliance 14
3.1. Complied with the GHS Legal Compliance Program to include Standards of
Conduct, Confidentiality of Information, Corporate Compliance and HIPAA
3.2. Complied with the GHS Uniform Regulation Policy to include having worn visible ID
badge at all times
3.3. Complied with the GHS Tobacco Free Policy
3.4. Complied with the GHS Attendance Policy (Unscheduled Occurrences)
3.5. Complied with the GHS Punctuality Policy (Tardiness and Early Departures)
4. Safety and Environment of Care 15
4.1. Demonstrated knowledge of his/her role regarding GHS Emergency Management,
Fire and Safety Policies.
4.2. Complied with and demonstrated knowledge of Workers Compensation Policy
4.3. Demonstrated the ability to perform assignments in a safe manner to avoid injuries
4.4. Followed all guidelines/standards in practice per CMS, JC, CAP, CLIA, DHEC etc.
and any/all other applicable accrediting agencies including but not limited to State
6
4
4
4
4
3
4
4
2
2
3
3
3
3
2
4
3
4
4
2
Value
Category
Please refer to the Performance Appraisal
User’s Guide prior to scoring any general
standard
Exceeded
Not
Met
Met
Key: Exceeded x 2, Met x 1, Not Met = 0
and Federal regulatory agencies
5. System Mission and Values 34
5.1. Supported both departmental and organizational change
5.2. Promoted GHS and community involvement as evidenced by having volunteered for
committees, sought opportunities for involvement within GHS and/or the local
community
5.3. Demonstrated Teamwork per Customer Service identified behaviors
5.4. Demonstrated Respect per Customer Service identified behaviors
5.5. Demonstrated Accountability per Customer Service identified behaviors
5.6. Demonstrated Communication skills per Customer Service identified behaviors
5.7. Demonstrated Compassion per Customer Service identified behaviors
5
4
5
5
5
5
5
100
II Position Specific Standards (100) total points) Head Nurse RN
Point
Key: Exceeds x 2, Meets x 1, Needs to Improve = 0
2
1
0
N/a
Standard 6: Provided Medication Safety with BMV scanning, hand hygiene, patient
identification, medication reconciliation, patient medication education and
medication/narcotic administration.

Standard will have been met when
1. BMV scanning requirements are between 90% and 95%,
2. no more than (5) occurrences of not complying w/ proper hand
hygiene,
3. (0) occurrences of not having used patient identifiers per policy
4. no more than (2) occurrences not complying with medication
reconciliation
5. no more (2) occurrences of documention/ education patients re:
medication use.
6. no more than (2) occurrences not complying with medication/narcotic
policies

1.
2.
3.
Standard will have been exceeded when
BMV scanning requirements are 96% - 100%
(3) or less occurrences of not complying w/ proper hand hygiene,
(0) occurrences of not having used patient identifiers per policy,
30
3
4.
5.
6.

(1) or less occurrences not complying with medication reconciliation
(0) occurrences of documenting education re: medication use.
(0) occurrences not complying with medication/narcotic policies
Standard will have not been met when (2) or more met expectations have been
compromised.
Standard 7 : Demonstrated Critical Thinking Abilities with patient care, physician
contacts, and Administrative House Supervisors.
.Standard will have been met provided
1. no decisions were made compromising a patient’s safety or life threatening in
nature coupled with fewer than (2) occasions that decisions were
inappropriate.
2. Consistently demonstrated ability to handle emergent situations per Nursing
protocol with fewer than (2) recorded instances.
3. Appropriately contacted physicians using sound judgment utilizing SBAR for
pertinent information with fewer than (2) recorded instances of non compliance.
4. Coordinated after hour calls with the Administrative House Supervisors with
fewer than (2) recorded instances of non-compliance
10

1.
2.
3.
4.
5.

Standard will have been exceeded provided:
No decisions were made compromising a patient’s safety or life threatening in
nature
no occasions whereby decisions were inappropriate.
Consistently demonstrated ability to handle emergent situations per Nursing
protocol with no recorded instances of failure.
Appropriately contacted physicians using sound judgment utilizing SBAR for
pertinent information with (0) recorded instances of non compliance.
Consistently coordinated after hour calls with the Administrative House
Supervisors with no recorded instances of non-compliance
Standard will not be met should two or more “met” expectations be
compromised.
Standard 8 : Ensured documentation was completed on the following:

20
Standard will have been met provided:
1. No more than (6) errors exist documenting/review/updating patient
care plans, discharge education/instructions relevant to medical
condition
2. No more than (10) occurrences of not documenting post intensity pain
level;
3. Ensured no more than (2) occurrences of not having assessed skin
4
4.
5.
6.

Standard will have been exceeded
1. No more than (3) error exist documenting/review/updating patient care
plans, discharge education/instructions relevant to medical condition,
coupled with;
2. No more than (6) occurrence of not documenting post intensity pain
level
3. Ensured no occurrences of not having assessed skin upon admission
or reassessments per established nursing protocol;
4. Ensured no occurrences of inappropriate judgment re: restraints with
utilization of restraint alternatives where needed coupled with having
noted and initiated orders per policy with no occurrences of noncompliance;
5. Reported critical test results within policy and documented per
nursing protocol with fewer than (0) occurrences of non-compliance
and;
6.

upon admission or reassessments per established nursing protocol;
Ensured fewer than (2) occurrences of inappropriate judgment re:
restraints with utilization of restraint alternatives where needed
Reported critical test results per policy and documented per nursing
protocol with fewer than (3) occurrences of non-compliance and;
Assessed, reassessed and documented per nursing protocol patient
risk for falls with plan for initiating safety/Smart Lift Program with
fewer than (3) occurrence of non-compliance.
Assessed, reassessed and documented per nursing protocol patient
risk for falls per policy with plan for initiating safety with (0)
occurrences of non-compliance.
Standard will not have been met should two (2) or more met expectations be
compromised.
STANDARD 9: Management Skills
30

1.
2.
3.
4.
Standard will have been met:
by participating with 75% input for performance appraisals on time,
no more than (2) occurrences of unresolved employee conflicts,
no more than (4) errors in staffing,
75% of PI data submitted on time.

Standard will have been exceeded
5
1.
2.
3.
4.
by participating with 95% or > performance appraisals,
no more than (1) occurrence of unresolved employee conflict,
no more than (2) errors in staffing,
submission of 100% PI data on time

Standard will not be met should (2) or more met expectations be compromised.
Standard 10:
Completed Annual Goals per previous year’s performance appraisal
10.1 Participates in goal setting
10.2. Reports progress
10.3. Completion of annual goals as per previous year’s performance appraisal
10
Measurement:

Standard will have been met if the employee sets annual and completes annual
goals.

Standard will have been exceeded if the employee sets annual completes;
coupled with semi-annual progress reports discussed with the Surgical Services
Director.

100
Standard will not have been met if the employee fails to set annual goals.
Subtotal Points - Section II Position Specific Standards
Total Points- Position Specific Standards: Add points from above two columns
Subtotal Points – Section I General Standards
Total Points- General Standards: Add points from above two columns
Grand Total Points – Add both “Total Column Points” together
Georgetown Hospital System - Employee Acknowledgement of Confidentiality,
Conflict of Interest and Corporate Compliance/Standards of Conduct
___________________________
Employee Signature
____________
Date
6