DEPARTMENT: QUALITY IMPROVEMENT
F ACILITY: Medical Office Building
WORK TYPE: Full Time
S HIFT: Daytime
SUMMARY:
The primary functions of this position are to maintain concurrent review and intervention in the timely completion of recognized best practice indicators as identified by regulatory agencies and hospital quality improvement priorities and to facilitate quality improvement initiatives throughout the various departments within the organization.
RESPONSIBILITIES:
* Initiates case finding according to pre-determined criteria to identify patients that are appropriate for quality indicator monitoring.
- Facilitates the documentation of identified indicators and care delivery consistent with evidence based practices and regulatory requirements.
- Develops and reports discrepancies and outcomes.
- Coordinates quality improvement initiatives utilizing proven quality improvement principles, bringing suggestions for improvement in processes to ensure compliance with quality indicators, and management and feedback of team performance data.
- Intervenes concurrently as able to ensure compliance with care provision in accordance with evidence based practices and quality indicator measures.
- Models and coaches the principles of high reliability, safety culture, and continuous learning.
- Maintains information and current knowledge of quality indicator measures, resource management, performance improvement, patient education, and discharge planning processes, including philosophy and principles.
- Applies the appropriate QI tools and methods for successful quality and process improvement projects.
- Develops and maintains professional working relationships with physicians, nursing staff, and other health care providers.
- Abstracts quality measure criteria in the electronic health record.
- Reviews care encounters to identify complications and quality improvement opportunities.
- Applies change management principles.
- Applies patient safety, just culture, and high reliability principles.
- Proficient in the use of QI Macros.
- Creates learning opportunities and materials to advance the organization.
- Demonstrates the ability to facilitate teams and teamwork.
- Keeps abreast of all pertinent federal, state and facility regulations, laws and policies as they presently exist and as they change or are modified.
- Understands and adheres to compliance standards as they appear in the Corporate Compliance Policy, Code of Conduct, and Conflicts of Interest Policy.
- Demonstrates age-specific skills as required by position.
- Offers suggestions on ways to improve operations of department and reduce costs.
- Attends all mandatory education programs.
- Improves self-knowledge through voluntarily attending continuing education/certification classes.
- Maintains required competency levels as identified in written exams, skills checklists, skills labs, annual safety and health requirements as well as service excellence education hours requirements.
- Willing to cross-train in order to better assist co-workers and to provide maximum efficiency in department.
- Volunteers/participates on hospital committees, functions, and department projects.
- Manages resources effectively.
- Reports equipment in need of repair in order to extend life of equipment.
- Makes good use of time so as to not create needless overtime.
EDUCATION:
* Bachelor's Degree in Nursing
CREDENTIALS:
* Registered Nurse
OTHER INFORMATION:
Three years healthcare experience required. Experience in quality improvement teams and knowledge of quality improvement methodologies preferred. Lean/Six Sigma education preferred. Experience with computer programs, data management, and quality improvement preferred. Requires organization, attention to detail, and application of quality improvement methodologies. Must work in a professional manner with internal and external customers to facilitate quality and safety improvement and quality measures abstraction, analysis, and sharing.
COMPETENCIES & SKILLS:
* Adapts to changing business needs, conditions, and work responsibilities and works with a variety of situations, individuals, groups, and varying customer needs.
- Patient care plan establishment and evaluation
- Manages, leads, and enables the process of change and transition while helping others deal with the impacts.
- Data analysis and reporting
- Data presentation
- Data querying
- Is reliable and trustworthy while performing work in a consistent and timely manner.
- Electronic medical record software
- Displays an ongoing commitment to learning and self-improvement and makes an effort to acquire new knowledge or skills for work.
- JCAHO and CMS regulation knowledge
- Possess the technical knowledge necessary to safely and efficiently perform job.
- MS Office
- Conveys ideas and facts orally using language the audience will best understand.
- Manages own time, priorities, and resources to achieve goals.
- Statistical analysis
- Promotes cooperation and commitment within a team to achieve goals and deliverables.
- Conveys ideas and facts in writing using language the reader will best understand.
Southwell/Tift Regional Health System, Inc. is an Equal Opportunity Employer.