Responsible for the collaborative development and implementation of a quality assessment and performance improvement program for the system.
Maintains knowledge of, and complies with, all relevant laws, regulations and policies, procedures and standards.
Actively participates in creating and implementing improvements to achieve clinical, satisfaction and/or efficiency outcomes.
Partners with system leaders to coordinate the Quality Program and develops, implements and maintains an effective, ongoing hospital-wide, data driven quality assessment and quality improvement program. Assesses quality for the defined patient population and determine priorities for performance improvement.
Provides basic support for the Clinical Councils in partnership with the physician and nursing leadership. Develops and maintains a current quality plan, develops and provides ongoing support for scorecards and data needs, reviews quality measurement data on a regular basis and to identify, prioritize and monitor improvement activities.
Collaborates with leadership to analyze data from the electronic safety reporting system and develops priorities for improvement including. Reviews all events and assures accuracy with consistently applied definitions, assures events are reviewed by all involved leaders and closes event when complete.
Partners with leaders and system experts around patient safety efforts. Oversees the Root Cause Analysis process (RCA), facilitates and documents event details, works with team to create robust action plans, implements changes. Completes all required processes for reporting and documentation for all reportable adverse health events.
Completes mortality reviews. Identifies and reports those which require notification to regulatory agencies, reviews for quality issues and opportunities to improve Failure to Rescue and refers to appropriate leaders.
Serves as the chapter expert for selected Joint Commission chapters and CMS conditions of participation, including Performance Improvement and the National Patient Safety Goals. Serves as a consultant during surveys involving the Joint Commission, CMS, MDH and other regulatory agencies. Oversees the selection and completion of required FMEA activities.
Partners with leaders and the data/informatics team to design effective measurement plans. Develops and provides and ongoing support for scorecards and data needs, reviews quality measurement data on a regular basis and to identify, prioritize and monitor improvement activities.
Prepares analysis of clinical data, including the identification and abstraction of appropriate data. Serves as the subject matter expert for the functionality of the electronic event software suite.
Experience:
3 to 5 years nursing experience required in a clinical setting. Experience in Quality, Performance Improvement and working with regulatory requirements, including experience in working with physicians, leaders and staff. Experience in leading multidisciplinary teams, and accreditation/ regulatory surveys. Extensive experience in Quality, Performance Improvement, Data abstraction and interpretation, Software management, and regulatory requirements.
Knowledge:
Knowledge of quality and improvement principles, tools and methods.
Knowledge of regulatory requirements, including Joint Commission and CMS Skills in Microsoft Word,Excel and PowerPoint. Data management skills.
Clinical knowledge base with review and assessment of clinical records and data.
Evidence-Based Practice knowledge and skills.
HealthEast Care System® is the largest not-for-profit health care system in the East Metro, with four hospitals and fourteen clinics. We have been named one of the Top 100 “Best Places to Work in HealthCare” in the nation by Modern Healthcare and one of the Top 10 health systems nationwide by Thomson Reuters. To apply online http://bit.ly/1SVVkUl For more information on HealthEast Care System, visit our website at: www.healtheast.org
Job details are sourced from the employer's original posting.
Open job postingAbout the company
At HealthEast, our patients are our neighbors and we are dedicated to their, and our, optimal health and well-being. We are guided by our faith-based heritage, a call to healing that respects the dignity and culture of every person. We empower our patients with user-friendly access to their health information, dependable service, and affordable, high-quality care. We put new, more efficient models of care into practice, allowing our 7,500 employees and 850 physicians to focus on what’s important: providing compassionate health care that puts the patient and their needs first. With 14 clinics, home care, a medical transportation center, and four hospitals — Bethesda Hospital, St. John’s Hospital, St. Joseph’s Hospital, and Woodwinds Health Campus — we provide excellent family health and specialization, including primary, maternity, orthopaedics and post-acute care.