Leader Within
Reflective Practice
Competency: Demonstrates strong leadership by improving team performance and engagement through regular evaluations, active participation in unit initiatives, effective communication, and timely responses to operational challenges.
Measurable Indicators:
- Increase leadership confidence by ≥5% through peer/self-assessment tools.
- Attend ≥90% of leadership meetings and ensure 95% closure on unit initiatives via documented follow-through.
· Conduct quarterly 1:1 evaluations with direct reports, resulting in ≥5% improvement in team performance metrics.
· Lead daily huddles with ≥90% staff participation, using them for feedback and post-incident debriefs.
- Document and deliver feedback at least quarterly to staff and leadership on performance and process improvements.
Career Development
Competency: Champions professional development and inclusive mentorship by guiding future leaders, fostering mentee growth, participating in continuous education, and promoting access to advancement opportunities, resulting in measurable staff engagement and leadership readiness.
Measurable Indicators:
· Mentor one or more staff yearly with ≥80% mentee-reported growth.
· Identify and train one future leader annually with tracked leadership progress.
· Support diverse, inclusive mentor/preceptor pool via annual review and adjustment.
· Attends at least one leadership conference or professional development seminar annually, implementing at least one new learned strategy on the unit. (i.e. LDI)
· Facilitates an easier process for staff to obtain tuition reimbursement for continuous learning, resulting in a 10% increase in staff pursuing higher education.
Foundational Thinking
Competency: Demonstrates foundational thinking through critical problem-solving, performance alignment, data-driven decision-making, empowerment, innovation, and continuous learning to enhance operational efficiency and staff engagement
Measurable Indicators:
· Effectively addresses ≥90% of unit-level challenges through independent decision-making or staff empowerment,
· Implement at least one new protocol annually to improve efficiency or safety—validated through audit and performance metrics.
· Achieves ≥95% staff understanding of unit expectations through regular workflow audits (e.g., daily intake, OVR reviews), proactive identification of improvement opportunities, and strategic recognition of positive practices—targeting a ≥5% quarterly increase in staff recognition submissions and consistent audit outcomes showing low ambiguity.
Personal and Professional Accountability
Competency: Demonstrate leadership through introspection, emotional intelligence, and flexible response.
Measurable Indicators:
- Complete annual self-assessments with action plans for improvement.
- Receive “role model” ratings in 85% of peer/direct report evaluations.
- Obtain or maintain a national certification.
- Maintain 100% compliance with all required licenses, certification (i.e. RN, ACLS, BLS, CHEMO), and continuing education units (CEUs) as evident by annual verification.
- Participates in leadership shadowing experiences at least twice per year to enhance organizational understanding.
- Implement two Individual Development Plans (IDPs) annually, with 80% goal completion.
- Participate in a Jackson Leadership Development Program (i.e. Leading at Jackson)
- Participate in at least one Shared Governance Council
Professionalism
Profession Accountability
Competency Statement: Ensures adherence to all professional standards, maintaining licensure compliance and ethical decision-making while demonstrating integrity in leadership.
Measurable Indicators:
· Ensures 100% of direct reports maintain active licensure and certifications.
· Demonstrates integrity in decision-making, with zero documented complaints of unethical behavior.
Health Equity and Social Determinants of Health
Competency: Promote respect in the workplace and moral courage in leadership and care.
Measurable Indicators:
- Lead or participate in one advocacy initiative or community engagement activity annually to support staff or patient rights.
- Serves as an effective ANM representative in relevant meetings, ensuring staff perspectives are heard and addressed.
· Ensures patient and family advocacy concerns are addressed in 100% of observed instances during rounding and direct interactions
Competency Statement: Ensures equitable healthcare practices by implementing policies that address social determinants of health and promote culturally competent care.
Measurable Indicators:
- Implements unit-level policies to prevent communicable diseases, achieving 95% staff compliance.
- Ensures 90% of eligible patients receive proper screenings for social determinants of health through regular audits.
- Completes at least one cultural sensitivity training annually, applying principles to improve patient-centered care.
- Demonstrates social awareness, contributing to a 5% improvement in patient satisfaction scores related to cultural sensitivity.
Organizational Accountability
Competency Statement: Takes ownership of unit-level challenges, proactively leading resolutions and ensuring service recovery through professional accountability.
Measurable Indicators:
· Addresses 100% of identified unit-level issues, evidenced by documented action plans.
· Resolves 100% of patient and staff concerns within 48 hours, ensuring 90% satisfaction with recovery efforts.
· Completes one leadership development course annually, applying learned principles to improve unit operations.
Governance
Competency Statement: Demonstrates strong leadership, fostering a culture of transparency, communication, and interdisciplinary collaboration to enhance team performance and patient outcomes.
Measurable Actions:
· Promotes a Just Culture, increasing incident reporting by 10% without fear of retaliation.
- Ensures staff feel empowered to speak up, achieving 80% participation in anonymous feedback mechanisms.
- Records Zoom meetings for night shift staff, ensuring 90% viewership and equitable information access.
- Utilizes bi-weekly administrative days for strategic planning and compliance review.
- Leads or participates in at least two hospital-wide multidisciplinary collaboration initiatives annually to drive improvements.
- Organizes regular town hall meetings, achieving 70% staff attendance or engagement to enhance communication.
Communication and Relationship Building
Relationship Management
Competency: Cultivate a high-performing team through mentorship, career planning, and development programs.
Measurable Indicators:
- Implement strategies and initiatives to reduce voluntary nurse turnover by 10% annually.
- Serve as a mentor to at least one staff member annually, with documented career progress.
- Ensures staff maintain 100% compliance with all required licenses, certification (i.e. RN, ACLS, BLS, CHEMO), and continuing education units (CEUs) by the assigned due date.
- Achieves 90% staff engagement and buy-in for new initiatives, as measured by participation rates.
- Ensures 80% of staff actively participates in the unit-based council (UBC), as measured by attendance and contribute to action plans.
Effective Communication
Competency: Facilitate transparent, two-way communication that builds trust, provides timely feedback, and promotes staff involvement.
Measurable Indicators:
- Conduct quarterly 1:1 with individual staff using standardized tools and incorporate rationale explanations (“the why”) into all new policy or procedural discussions.
- Provide real-time care-based feedback and recognition to assigned staff at least twice monthly.
- Maintain a current communication board/book that is updated weekly for shift coverage, updates, and staff news, and monthly “closing the loop” using a tracker (e.g., Stop Light or A3 report).
- Follow up on staff concerns within 5 business days of identification.
- Collaborate with colleagues to use consistent messaging across shifts, using multiple formats (verbal, written, and/or digital – i.e. Tiger Connect).
Influencing Behaviors
Competency: Promote interdisciplinary teamwork and cross-functional relationships to improve patient outcomes and foster a collaborative environment.
Measurable Indicators:
- Attend and participate in interdisciplinary rounds/MDR (with MDs, RTs, EVS, etc.).
- ≥70% involvement of frontline staff in interdisciplinary initiatives with tracked behavioral outcomes
- ≥10% improvement in team trust and openness scores through monthly team-building and structured feedback.
Knowledge of Health Care Environment
Nursing Practice and Application
Competency Statement: Ensures high-quality patient care by maintaining clinical competency, fostering interdisciplinary teamwork, and implementing evidence-based practices.
Measurable Indicators:
· Demonstrates ability to verbalize and perform basic nursing competencies in all patient care scenarios.
· Communicates, coordinates, and plans nursing care effectively within interdisciplinary teams.
· Advocates for consistency and continuity of care, ensuring seamless transitions between nursing shifts.
· Engages in monthly and ad-hoc collaborative meetings with critical care teams to drive patient-centered improvements.
Regulation
Competency Statement: Ensures adherence to hospital policies, regulatory standards, and effective resource management to maintain a high-performing unit.
Measurable Indicators:
- Successfully implements 100% compliance with hospital policies and procedures, including Welearn and Care Tactics, within the designated timeframe.
- Ensures unit maintains a 95% compliance rate on internal and external regulatory audits.
- Support completion of compliance with checklists within 30 days post mock surveys.
- Support education on CMS/Joint Commission standards regularly.
- Achieve 90% Environment of Care compliance, with all corrective actions resolved on time.
Economics and Policy
Competency Statement: Promotes adherence to hospital policies and financial regulations by educating staff on best practices and ensuring timely documentation.
Measurable Actions:
- Educates staff on proper documentation, billing, and discharge protocols to enhance financial accountability.
- Implements timely policy updates, ensuring staff compliance with economic and regulatory standards.
Evidence Based Practice
Competency Statement: Ensures the application of patient safety principles and improvement science to enhance care quality and prevent adverse events.
Measurable Indicators:
- Drive 2 new evidence-based practice changes annually, improving patient outcomes.
- Monitors and tracks patient safety metrics, leading to a 5% reduction in preventable incidents annually.
- Actively participates in patient safety initiatives, fostering a culture of continuous improvement.
Patient Safety and Quality
Competency: Use data-driven strategies to promote continuous improvement and shared accountability.
Measurable Indicators:
- Facilitate continuous improvement projects using the appropriate tools (i.e. PDSA, A3 Lean tools).
- Present performance metrics regularly to engage and motivate staff.
· Conducts quarterly quality audits, achieving a 10% improvement in compliance with safety standards.
- Review call light report each shift for outliers response over 5 minutes and connect with the individual nurse and PCA to understand the barrier to timely response, and provide the follow-up to the manager before the end of each shift.
Business Skills and Principles
Financial Management
Competency: Lead safe, efficient, and evidence-based care across diverse settings.
Measurable Indicators:
- Reduce patient discharge time by 10% through workflow and interdisciplinary optimization, as evident by Qventus (where applicable) or data provided by the organization.
- Decrease hospital-acquired conditions (e.g., CAUTIs, CLABSIs) by 15% annually
Competency: Demonstrates a high level of proficiency in managing the financial and operational aspects of medical supplies and equipment to ensure delivery of high-quality patient care while optimizing resource utilization and cost efficiency.
Measurable Indicators:
- Achieves 5% reduction in sterile supply waste and optimizes Omnicell management annually.
- Maintains unit productivity targets, reducing incremental overtime by 3% annually.
- Adjusts staffing daily/hourly based on patient acuity, improving staff utilization by 2%.
- Maintains PAR levels at minimums for 95% of unit supplies, preventing overstocking and waste.
- Implements at least two cost-saving measures annually for medications or supplies.
- Implements inventory control measures, reducing expired or unused supplies by 10% annually
· Ensures 95% of unit equipment remains functional, minimizing rental or repair costs.
· Promoting accountability and ownership of equipment to prevent loss or breakage.
Human Resource Management
Competency Statement: Ensures efficient management of unit staffing, and quality performance to enhance operational effectiveness and patient care outcomes.
Measurable Actions:
· Maintains 95% compliance with budgeted FTEs, optimizing staffing levels.
Strategic Management
Competency: Drive strategic planning and solve unit-level challenges through critical and foundational thinking.
Measurable Indicators:
- Lead one strategic initiative to support the nursing strategic plan.
Leadership
Systems and Complex Adapting Thinking
Competency: Lead unit operations through accountability, productivity analysis, policy compliance, and collaborative problem-solving.
Measurable Indicators:
- Maintain unit productivity between at 100% using MyHQ and timekeeping systems.
- Achieve ≥98% compliance on policy audits; initiate action plans for any variances.
- Improve patient experience scores through targeted initiatives aligned with facility goals.
- Collaborate on cross-disciplinary and/or inter-unit process improvement initiatives annually.
Change Management
Competency: Navigate and lead change by fostering psychological safety, challenging norms, and embedding evidence-based practices and governance structures.
Measurable Indicators:
- Achieve ≥90% staff adoption of new processes within 30 days of rollout, using a structured communication plan for the change.
- Use RLDatix to support safety event reporting with review documented within 72 hours.
- Challenge legacy practices in ≥80% of identified instances during change rollouts.
- Participate in Failure Mode & Effect Analysis (FMEA) sessions and shared governance efforts tied to policy improvements.
- Manage and de-escalate workplace conflict using prevention and resolution strategies and using de-scalation techniques.
Respect in the Workplace
Competency: Create a culture of inclusion, respect, and recognition through intentional communication, empathy, and diverse learning support.
Measurable Indicators:
- Maintain professional communication with no substantiated tone-related complaints and use mindful body language, as self-assessed or using peer feedback.
- Provide care-related or emotional support in a quiet, private area when addressing sensitive issues.
- Promote CARE badge program participation and peer recognition monthly.
- Ensure diversity in mentors and preceptors for equitable new staff onboarding.
- Actively listens to patients, family, and staff concerns, escalating 100% of critical concerns to the appropriate leadership with documented follow-up.
Decision Making
Competency: Make informed, collaborative decisions aligned with organizational goals through structured problem-solving and staff engagement.
Measurable Indicators:
- Incorporate quality and operational data into decision-making processes.
- Ensure all delegated tasks have 100% documented follow-through.
- Lead decisions aligned to strategic goals; engage staff through huddles and shared governance.
- Follows the established chain of command for all critical decisions.
Transformation and Innovation
Competency: Strengthen morale and staff engagement through presence, recognition, debriefing, and emotionally intelligent coaching.
Measurable Indicators:
- Round proactively to support team wellness, including temperature checks on morale and needs (i.e. breaks).
- Provide on-the-floor assistance at peak times (i.e. shift change, codes) demonstrating hands-on leadership.
- Conduct post-incident debriefings, per policy, with involved staff to support psychological safety (i.e. rapid response, codes).
- Celebrate achievements visibly, or in the way staff want to be appreciated, consistently (e.g., CARE badges, thank you notes, huddle shout-outs, bulletin boards) at least 5 times per month.
- Adjust appreciation tactics based on annual staff feedback.
- Use educational non-punitive coaching, within 48 hours of concern or the next scheduled shift, for first-time or minor performance issues to promote growth, and document in the appropriate tool.
Competency: Build shared ownership of goals by encouraging staff leadership, consensus building, and empowerment.
Measurable Indicators:
- Delegate one huddle leadership monthly to staff, rotating participants.
- Engage team members in unit council participation and operational decision-making forums.