Job Abstract

Summary

• Acts as an internal quality consultant for the hospital at all levels.
• Assists in identifying quality improvement opportunities within the organization, prioritizes the opportunities, and collaborates with leaders, project managers, and clinicians in the planning and initiating of action plans.
• Participates in RCAs/ACAs and event reviews, and continues follow-up on action items until event closure.
• Develops and enhances quality management education and infrastructure as assigned.
• Shares findings from quality reviews and projects with appropriate leaders and committees that support implementation and completion of effective action plans.
• Assists with coordination and implementation of the organization-wide Quality Plan and Program.
• Coordinates, facilitates and reports on Quality Improvement Projects.
• Completes medical record reviews, compares current practice against best practice guidelines and provides recommendations to improve patient care.
• Supports Medical Staff Peer Review Coordinators with identifying evidence-based practices to support peer review activities and actions identified from peer review trends.
• Supports Multidisciplinary Committees for any quality improvement activities generated.
• Monitors compliance with project progress relative to timelines and deadlines; monitors impact of short and long-term compliance with implemented action items using an auditing process as applicable.

Compliance: Ensures compliance with state, federal and TJC regulations.

• Plays a role in ensuring compliance with all State and Federal contractual requirements regarding quality management.
• Collaborates with Accreditation and Regulatory Readiness staff to ensure regulatory standards are being met; participates in regulatory readiness activities; assists when there is a regulatory agency on site.
• Verbalizes knowledge of local, federal, and state laws and regulations as well as TJC standards related to their position.
• Responds to regulatory agencies quality concerns.

Data Management: Implements and maintains a system for identifying, collecting, analyzing and reporting of performance data.

• Participates in data collection/analysis of process or outcome measurements, including but not limited to Core Measures.
• Identifies patterns and trends during event reviews, and in collaboration with Risk and Patient Safety team members, identifies serious or sentinel events.
• Supports designing projects, coordinating and/or performing data collection, and developing action plans.
• Collaborates with action plan project leaders to create timelines and deadlines for each project.
• Gathers and enters data for clinical improvement measures, quality reviews and medical staff indicators.
• Prepares data for submission to appropriate departments, committees, and regulatory entities within required timeframe.

Professionalism: Maintains the utmost professionalism at all times.

• Communicates with management/stakeholders to determine appropriate courses of action prior to enacting changes in processes.
• Addresses requests promptly and courteously, honors commitments and displays persistence in obtaining information necessary for report completion, verification or analyses.
• Uses discretion and, when appropriate, obtains approval prior to releasing sensitive information. Upholds confidentiality in all aspects of job performance. Performs other related duties and projects as assigned.

QUALIFICATIONS AND REQUIREMENTS:

• Basic professional knowledge; equivalent to a Bachelor's degree; working knowledge of theory and practice within a specialized field.
• Bachelor's degree in Nursing (BSN) required; 7+ years of total experience with 3-5 years of quality improvement and patient safety.
• Maryland Registered Nurse License (RN).
• American Heart Association CPR (BLS).
• Certification CPHQ preferred.

Additional Information