POSITION SUMMARY:

Oversees projects while assisting clinical and non-clinical team members make improvements to patient care, safety, efficiency and customer service. Takes an active role in helping departments standardize good practice patterns. Promotes compliance with regulations by working with ECHN staff to develop practices that are relevant and compliant. Facilitates project teams as well as organizational department efforts to improve systems and process within ECHN. Acts as a resource person to administrative team, department managers and medical staff. Supports medical staff departments and committees in their peer review, quality and service excellence efforts. Compiles and assists with the analysis of internal and external data. Reports to the Vice President of Quality.

 

EDUCATION/CERTIFICATION:

Bachelors of Nursing or related field required. Masters Degree in Nursing or related field preferred.

EXPERIENCE:

Strong patient advocate. Minimum of 5 years clinical experience. Previous quality, safety and or regulatory experience preferred. Experience with database/spreadsheets is helpful.

COMPETENCIES:

Strong leadership skills, attention to detail and excellent communication skills. Ability to maintain confidentiality.

ESSENTIAL DUTIES and RESPONSIBILITIES:

Disclaimer: Job descriptions are not intended, nor should they be construed to be, exhaustive lists of all responsibilities, skills, efforts or working conditions associated with the job.  They are intended to be accurate reflections of the principal duties and responsibilities of this position.  These responsibilities and competencies listed below may change from time to time.

 

Job-Specific Competency

1.      Assists and directs leaders in the development of appropriate Performance Improvement (PI) and Service Excellence plans, projects and reports for their areas/departments.

2.      Assists department leaders in the formulation of measurable outcomes data including guidance to the technical collection and presentation of data.

3.      Facilitates hospital level projects and teams, ensuring timely progression through the PI cycle. 

4.      Utilizes appropriate QI tools to investigate and examine events and processes, e.g. RCA, FMEA.

5.      Demonstrates up-to-date knowledge and application of JCAHO, State and Federal standards.

6.      Coordinates the preparation of the organization for review/survey by regulatory agencies (JCAHO, DPH, CMS).  Educates and assists department managers to maintain appropriate compliance with standards, regulations and patient expectations.

7.      Assists VP, QI in planning and implementation of plan of correction/improvement for survey/core/satisfaction deficiencies.

8.      Supports the Risk Management program by appropriately screening occurrences and identifying those requiring reporting and/or further investigation or action plans.

9.      Assists with the collection of data, analysis and display of information, development, implementation, and follow-up action plans to ensure improvement is achieved.  (CORE measures, blood utilization, medical records, moderate sedation, satisfaction, etc.) and retains involvement until closure.

10.  Provides the Medical Staff Department Chairs with case reviews/reports and screening information that is accurate and timely.

11.  Performs other duties as assigned or directed to ensure smooth operation of the department and organization.