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Job Description
Job Summary: This job is responsible for coordinating performance improvement and regulatory compliance initiatives/processes for 1) Emergency Services, 2) Perioperative Services or 3) Hospice to address and strengthen patient safety, utilization of clinical resources, achievement of desired clinical outcomes and to facilitate achievement of overall financial goals and business/patient satisfaction objectives. An incumbent serves as project manager for a variety of management-level work teams, providing support, expertise and guidance in: 1) the application of accepted clinical quality improvement methodologies/tools; 2) data collection and statistical/operational analysis; 3) outcomes measurement; 4) risk assessment; 5) best practices research; 6) documenting and implementing process improvements; and 6) evaluating desired vs. actual clinical effectiveness of performance improvement efforts. Work requires strong clinical nursing expertise and an understanding of patient care standards/practices and applicable regulatory requirements. Knowledge of project management and quality improvement concepts, methodologies and tools, and of the importance of data to performance improvement processes is also required. Although work is conducted using a team-based approach, an incumbent exercises considerable discretion and independent judgment in identifying non-compliance issues/concerns and in developing/implementing effective tactics/solutions to address and resolve them. In this respect, an incumbent must be sufficiently savvy to state the problem, causes thereof, risk exposures and recommended corrective action that assures management that action to resolve the problem is necessary, will be effective and is adequate. Assumptions may be challenged and may require understanding relationships across functions/departments to anticipate larger risks. Working directly with clinical management in identifying issues and implementing changes requires tact and sensitivity in communication efforts. Essential Duties:- Evaluates patient care activities in relation to MBO standards of care and applicable regulatory requirements; analyzes and assesses clinical practices (e.g. 'tracers') for opportunities to improve healthcare delivery for the assigned department; identifies quality/performance improvement opportunities and recommends strategies and practices to increase productivity/efficiency, improve clinical outcomes and enhance patient safety; gains consensus as to performance improvement projects to be undertaken.
- Develops and facilitates, in conjunction with physicians, nurse leadership and clinical staff, performance improvement team projects; ensures that adequate resources are available and tracks/monitors progress towards achieving key objectives.
- Plans and conducts internal reviews/audits to ensure that department operations are conducted in compliance with all regulatory requirements/guidelines; develops appropriate audit tools to measure compliance; analyzes and presents data to identify existing or potential problems; develops and implements compliance and performance improvement plans to ensure readiness for audits/surveys conducted by external agencies (e.g. JCAHO).
- Serves as point-person for risk management issues/concerns relating to the assigned department; researches and develops formal responses to citations/findings; participates in the development/implementation of action plans that address risk management/safety issues specific to the assigned department, and monitors adherence thereto; identifies continuing issues and works with Risk Management staff to resolve.
- Investigates and responds to grievances and patient complaints directly and/or refers them to appropriate internal resource (e.g. Patient Advocate); follows up to ensure issues are responded to and documented in a timely and professional manner and are consistent with MBO service recovery standards.
Job Requirements
Education: - Graduate of an accredited school of nursing.
- Bachelor of Science in Nursing is preferred.
Experience:- Five years of progressively responsible related work experience.
- Depending on the assigned department, specialized work experience is strongly preferred.
- An equivalent combination of qualifying experience and education may be substituted for up to two years of the education requirement.
License/Certification:- Current State Licensure as a Registered Nurse required.
- BLS required.
- If assigned to Perioperative Services, current CNOR is required upon hire or within one year of employment in the position.
Additional Responsibilities:- Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
- Adheres to and exhibits our core values:Reverence: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.Integrity: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.Compassion: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.Excellence: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
- Maintains confidentiality and protects sensitive data at all times.
- Adheres to organizational and department specific safety standards and guidelines.
- Works collaboratively and supports efforts of team members.
- Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.
Catholic Health Initiatives and its organizations are Equal Opportunity Employers.
Shift: 08:00 - 16:30
Status: Full Time
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