Cqsp-Rn

Mahnomen Health Center•Mahnomen, MN

About The Position

The Clinical Quality & Safety Program Manager (CQSP) serves as the primary outpatient nurse, coordinating the safe, timely, and efficient delivery of outpatient services. The role develops, implements, and maintains compliance programs and a cost-effective system of care for trauma patients and their families across the continuum of care. It also coordinates organization-wide quality improvement, infection prevention and control, and workplace violence prevention activities. The CQSP works independently and collaboratively with the director of nursing, medical director, providers, administration, and clinical staff, and is part of the acute care RN pool. As an acute care RN, the CQSP provides nursing care to patients presenting to the emergency department or admitted to the hospital, using the nursing process of assessment, planning, intervention, implementation, and evaluation. The role requires prioritizing care, recognizing and responding to changes in patient condition, and collaborating with the interdisciplinary team to develop safe plans of care. The position coordinates outpatient services, including scheduling, clinical preparation, treatments, infusions, injections, procedures, and follow-up. It oversees or supports trauma program initiatives, quality and performance improvement, infection prevention, workplace violence prevention, clinical education, and community injury-prevention outreach. The role also participates in direct patient care, including responding to trauma team activations during work hours and providing acute care nursing as needed. This is a non-exempt position with 8–12-hour shifts. The salary range is $36.77–$51.48. The job description states that the employee may perform other reasonable related duties within the RN scope of practice and that management may change responsibilities, duties, and hours as organizational needs prevail.

Requirements

Completion of an accredited associate’s or bachelor’s degree in nursing; a bachelor’s degree is preferred.
Current Minnesota Registered Nurse license.
Three years of clinical RN experience in trauma or emergency care is recommended.
One year of infection prevention and quality improvement program experience is recommended.
Basic Life Support (BLS) certification upon hire or within three months of hire.
Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) certifications upon hire or within six months of hire.
Trauma Nursing Core Course (TNCC) or Comprehensive Advanced Life Support (CALS) certification upon hire or within one year.
Ability to establish and maintain effective interpersonal relationships and accept and implement change.
Problem-solving and decision-making ability, with critical-thinking, analytical, teaching/coaching, and research skills.
Ability to analyze and interpret complex information and determine action based on research, data, standards of care, and guidelines or protocols.
Effective oral and written communication with a wide variety of intra- and inter-facility staff and administration.
Flexibility to work nights, weekends, holidays, and on-call duty.
Proficiency with electronic medical records and computer skills; strong attention to detail and time-management skills.
Ability to withstand prolonged sitting, standing, walking, bending, and reaching; perform repetitive hand movements; and work on wet or damp surfaces.
Ability to bend, stoop, squat, crawl, crouch, kneel, balance, push, and pull; lift up to 35 pounds at times; and reach below, at, or above shoulder level.
Ability to withstand physical, emotional, and mental stress; may be exposed to infectious diseases and occupational dangers.
Ability to understand and distinguish speech or other sounds and detect and inspect surroundings.

Nice To Haves

Bachelor’s degree in nursing preferred.
Three years of clinical RN experience in trauma or emergency care recommended.
One year of infection prevention and quality improvement program experience recommended.

Responsibilities

Support and adhere to hospital policies, procedures, philosophy, and mission.
Produce and manage program budgets; interpret, develop, implement, and recommend revisions to policies and procedures.
Participate in planning program goals and objectives for trauma care, quality improvement, infection control, and workplace violence prevention.
Coordinate with nursing, medical, administrative, and clinical leadership to assess policy, procedure, and protocol needs.
Represent trauma, stroke, quality improvement, infection control, and workplace violence programs on hospital and community committees.
Monitor compliance with hospital policies, procedures, and standards through observation, medical-record review, staff feedback, and other appropriate sources.
Coordinate outpatient care, including scheduling, clinical preparation, treatments, infusions, injections, procedures, and follow-up.
Review outpatient orders for completeness and obtain clarification of incomplete or unclear orders before services are provided.
Coordinate with providers, pharmacy, nursing, prior authorization staff, referral sources, and other departments to prevent delays in care.
Monitor and appropriately route outpatient requests, referrals, calls, and faxed orders; identify and communicate barriers to treatment.
Ensure applicable medications, supplies, equipment, documentation, and authorizations are available before scheduled outpatient services.
Perform nursing assessment, monitoring, documentation, patient education, follow-up, and escalation of clinical concerns for outpatient services.
Implement trauma program initiatives and monitor compliance with statewide trauma system requirements.
Coordinate preparation for statewide trauma system designation site visits and participate in state and regional trauma care activities.
Respond to trauma team activations during work hours and assist in patient care as needed.
Develop collaborative relationships across hospital departments and serve as a trauma care resource for staff.
Collect, analyze, trend, and report quality and patient-safety data; coordinate multidisciplinary review of quality concerns, adverse events, and trends.
Assist departments with performance-improvement plans; facilitate root-cause analyses and structured reviews; monitor corrective actions and improvement initiatives.
Support regulatory, accreditation, and survey-readiness activities related to quality and patient safety.
Monitor trauma care performance and outcomes, participate in case reviews, and coordinate follow-up on patient-care issues.
Develop and monitor the trauma performance-improvement program with the trauma program medical director or co-advisor; coordinate multidisciplinary review meetings.
Manage trauma registry data, including collection, analysis, trending, validation processes, accurate entry, maintenance, and periodic reporting to the state trauma program.
Coordinate the organization’s infection prevention and control program; conduct surveillance and report infection data and trends.
Monitor infection prevention practices, investigate potential infections, exposures, outbreaks, and concerns, and coordinate follow-up and corrective actions.
Develop, review, and update infection prevention policies and procedures; participate in risk assessments and the infection prevention plan; collaborate with public health and regulatory organizations as required.
Coordinate the workplace violence prevention program, including policies, procedures, response plans, risk assessments, and mitigation strategies.
Track, investigate, analyze, and trend workplace violence incidents and staff safety concerns; recommend preventive or corrective actions and monitor their effectiveness.
Coordinate workplace violence education and collaborate with administration, nursing, human resources, security or law enforcement, and other departments.
Plan, coordinate, and evaluate trauma, QAPI, infection prevention, and workplace violence education for nursing staff; monitor applicable staff education requirements.
Develop and deliver orientation, nursing education, in-service programs, and education on patient safety, quality improvement, infection prevention, and regulatory requirements.
Collaborate with EMS and community representatives on injury-prevention programs, community trauma education, and EMS communication, education, and feedback.
Obtain and document nursing histories; assess patients according to their condition; administer prescribed medications and question orders when warranted by patient condition.
Identify and report abnormal findings or changes in patient status to the provider; accurately document pertinent information in the electronic medical record.
Use medical equipment appropriately, respond to life-saving situations, participate in peer review, pursue professional growth, and participate in discharge planning.
Supervise care provided by LPNs, CNAs, and nonprofessional staff; provide instruction and delegate appropriate tasks.
Communicate professionally with patients, visitors, and healthcare-team members; recognize safety hazards and take corrective action.
Use evidence-based practice and maintain attention to detail, time management, and proficiency with electronic medical records and computers.
Perform other reasonable related duties within the RN scope of practice as assigned.