Department: Quality Outcomes

FTE: 1.00
Full Time
Shift: Days

Position Summary:
Leads nursing quality improvement efforts across all inpatient and outpatient settings in the delivery of high-quality patient care, safety, and experience. Provides leadership, direction, and consultation to nursing leaders and clinical nurses regarding all patient quality and safety issues. Develops and implements programs and systems to meet organizational objectives. Provides focus on the improvement of work processes to reduce sources of error, trains others in quality improvement strategies, techniques, and develops an infrastructure to give nursing staff access to the problem-solving processes. Removes barriers to quality and promotes a positive, collective voice of nursing through transparency and Just Culture practices. Works with senior leadership to integrate annual quality goals of UNMH within nursing units and departments. Partners with nurses, providers, hospital executives, and leadership and managers to execute key performance improvement strategies. This position reports to the Executive Director of Quality with a matrixed reporting relationship to the Chief Quality Officer and CNO. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* DIRECTION - Direct activities of the department and/or programs in accordance with Hospitals policies and objectives
* SUPERVISION - Develop efficient organizational structure. Supervise employees and select, terminate, train, educate, correct deficiencies, perform appraisals, issue discipline, counsel, schedule work assignments; encourage staff teamwork and growth initiatives
* STRATEGIC INITIATIVES -Assists and provides support with initiatives to achieve annual strategic goals through sharing of data, teaching of quality improvement principles, and process improvement tools
* QUALITY PLAN - Assists CNO and designees in formulating an annual nursing quality plan
* TRAINING - Plans and actively participates in training of nursing and ancillary personnel on improvement tools to include Lean tools, and PDSA
* IMPROVEMENT - Facilitates improvement initiatives such as Patient Safety Investigations, Root Cause Analyses, and A3 problem statements for nursing related improvement opportunities
* DATA - Analyzes and interprets data for nursing quality indicators; partners with the Director of Professional Nursing Practice to interpret benchmark data on a national level for nursing quality indicator benchmarks such as NDNQI and Press Ganey
* SCORECARDS - Create and maintain nursing quality and safety scorecards aligned with organizational goals and national standards to promote transparency around quality improvements
* LIAISON - Serves as a liaison between the Hospital Quality department and clinical Informatics on nurse and quality related documentation issues
* MEETINGS - Attends appropriate nurse leader meetings as a representative of quality to develop and maintain collaborative partnerships with key stakeholders across the institution to positively impact nursing practice and patient care outcomes
* QUALITY & SAFETY - Works with other Quality Leaders to facilitate quality and patient safety initiatives as prioritized annually within the UOP
* COMPLIANCE - Ensure compliance with all regulatory agencies governing health care delivery and the rules of accrediting bodies by continually monitoring Hospital operations and programs and physical properties; initiate changes as required
* BUDGET - Develop and administer the division's annual budget; monitor and approve expenditures
* DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops
* PATIENT SAFETY 1 - Follow patient safety-related policies, procedures and protocols
* PATIENT SAFETY 2 - Demonstrate proactive approach to patient safety by seeking opportunities to improve patient safety through questioning of current policies and processes
* PATIENT SAFETY 3 - Identify and report/correct environmental conditions and/or situations that may put a patient at undue risk
* PATIENT SAFETY 4 - Report potential or actual patient safety concerns, medical errors and/or near misses in a timely manner
* PATIENT SAFETY 5 - Encourage patients to actively participate in their own care by asking questions and reporting treatment or situations that they don't understand or may "not seem right"

Education:
Essential:
* Bachelor's Degree
Nonessential:
* Master's Degree
* Training
Education specialization:
Essential:
* BSN or MSN
Nonessential:
* Nursing or Related Field
* Lean

Experience:
Essential:
3 years directly related experience

Nonessential:
No preferred experience

Credentials:
Essential:
* RN in NM or as allowed by reciprocal agreement by NM

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* Minor Hazard - physical risks, dirt, dust, fumes, noise
* Subject to an annual contract and performance appraisal