Coordinator Cardio Accreditation & Quality

Wellstar Health System•LaGrange, GA

19h•Onsite

About The Position

Provides leadership for the Cardiovascular Service Line Accreditation and Quality Program to promote excellence in patient care. This position will assist in the planning, development, and implementation of a comprehensive plan to provide complex care to Cardiovascular patient form prehospital EMS to access to post discharge medical care. This leader will be responsible for program goals and operations regarding all aspects of the Cardiovascular Service Line Accreditation and Quality program. Provides direction to establish, monitor and evaluate the quality of care given to Cardiovascular patients and to ensure our patients are provided with the highest quality of care with the goal of improving patient outcomes. Will have responsibility for implementing standards of practice, program policies and procedures, and maintaining and improving the quality of patient care delivered. Will create an environment which enables West Georgia Medical Center to fulfill its mission and goals by fostering communication and collaborative practice with physicians and other departments. Will ensure a constant state of readiness for all cardiac accreditations (Examples: TJC Primary Heart Attack Center (PHAC), Intersocietal Accreditation Commission Echo/Vascular, and Heart Failure) identified by the Wellstar System. An additional focus of this position is to provide vision and ensure the program stays attentive to current and future community needs.

Requirements

Bachelors Nursing or Accredited Program Nursing or Masters Nursing-Preferred
RN - Reg Nurse (Single State) or RN-COMPACT - RN - Multi-state Compact
BLS - Basic Life Support or ARC-BLS - Amer Red Cross Basic Life Support or BLS-I - Basic Life Support - Instructor
hold a privilege to practice in the State of Georgia under the Enhanced Nurse Licensure Compact (eNLC). Upon Hire Required
Minimum 3 years of cardiovascular nursing experience in an acute care environment Required
Computer/data entry experience. Required
Strong leadership, interpersonal, time management, change management, performance improvement, and project management skills.
Must have the ability to work independently and maintain focus on goal attainment.
Must possess a solid understanding of team dynamics.
Ability to communicate with various members of the healthcare team.
Ability to use Excel, Word, PowerPoint, and have basic computer operational knowledge.

Responsibilities

Assumes responsibility and leadership of the Cardiovascular Accreditation and Quality Program by collaborating with Cardiovascular Performance Improvement Committee (CV PIC), CV Committee (Cardiologist/Leadership), West Georgia (WG) Performance Improvement (PI) Committee, Clinical Nurse Managers, and Administrative Leadership in the development and achievement of the Cardiovascular Accreditation and Quality program at West Georgia Medical Center
Provides direction and strategic planning including the attainment of short and long term goals for the hospital Cardiovascular Accreditation and Quality program
Evaluates and ensures compliance with performance improvement activities defined through The Joint Commission (TJC) accreditation and the Quality initiatives
Completes all intracycle reports to be submitted to TJC within required time frame
Maintains communication with CV PIC, CV Committee, and WG PI Committee regarding on-going quality initiatives and accreditation projects within TJC guidelines.
Develops and provides education for staff necessary for the successful certification and recertification of all Cardiovascular Accreditation per Joint Commission guidelines
Assumes the role of Chest Pain Center Coordinator
Coordinates TJC Primary Heart Attack Center (PHAC) accreditation
Coordinates the STEMI Alert Response with all team members
Analyzes data for opportunities for STEMI improvement and follows up with stakeholders on review of each STEMI case within 24-48 hours.
Continuously evaluates standards of care to ensure cardiovascular care is consistent with current guidelines, recommendations, and evidence.
Develops and maintains clinical protocols/order sets and care paths and updates annually to reflect evidence-based practices. Monitors adherence to clinical protocols, tracks variances from protocols/care paths and reports outcome data to the CV PIC.
Works collaboratively with the CV Registries (examples: GWTG CAD, GWTG Heart Failure, NCDR Cath/PCI, and NCDR ICD) to achieve concurrent data collection. Assist with validation of accuracy, analysis, interpretation and making recommendations based on clinical outcomes data
Evaluates program data and collaborates with program team members for areas of success and opportunities for improvement.
Provides regular, timely feedback to leaders and direct care providers regarding CV performance and patient outcomes.
Ensures complete and timely follow up on all opportunities for improvement in CV clinical care.
Serves as a liaison between clinical departments, EMS, and physician offices by providing feedback on patient outcomes and analyzing individual dept. performance regarding established goals.
Meets regularly with the CV Service Line Leader to assure cohesive integration of Cardiac Care.
Regularly attends all Cardiac Performance Improvement Committee meetings at West Georgia in addition to all Cardiovascular System Service Line meetings.
Provides timely updates to all performance improvement committees regarding all performance improvement initiatives.
Teams up with Physicians to ensure metrics and standards are achieved per current guidelines.
Identifies potential barriers to success in performance improvement, communicates the nature of those barriers, and works collaboratively with hospital and system leadership to overcome barriers.
Coordinates efforts across all cardiovascular programs to ensure consistent communication, efficient resource utilization, and standardization of care processes.
Serves as project manager with timeliness in initiatives as assigned
Defines scope of service, goals and objectives for the Cardiovascular Accreditation and Quality program.
Develops and updates program policies and associated communication documents.
Effectively communicates program expectations to team members in a timely and clear fashion.
Estimates resources and participants needed to achieve program goals.
Sets and continually manages program expectations with team members.
Delegates tasks and responsibilities to appropriate personnel.
Identifies and resolves issues and conflicts within the Cardiovascular Accreditation and Quality program.
Plans, schedules, and tracks project timeliness and milestones using appropriate tools.
Develops and delivers progress reports, proposals, required documentation and presentations as assigned.
Documents and facilitates the presentation of current PI activities to the CV PIC utilizing A3 thinking (Plan-Do-Check-Act) and Lean/Six Sigma resources and tools.
Manages changes in project scope, identifies potential crises and devises contingency plans.
Coaches, mentors, motivates, and supervises Cardiovascular Accreditation and Quality team members and influences them to take positive action and accountability for their assigned work.
Develops and maintains Cardiovascular Accreditation and Quality website
Clinical expert for cardiovascular patient care to hospital staff/personnel and other health care professionals within the organization and community.
Participates in identifying learning needs, planning, and implementing educational programs on an annual basis for those areas involved in the CV focus areas of certification.
Serves as a resource to emergency services, cardiology, inpatient nursing, and physician practices to ensure cohesive cardiovascular patient care.
Collaborates with CV Nursing Units to ensure proper planning and facilitation of education is following current standards to improve clinical outcomes.
Works collaboratively with CV leadership to plan and implement community outreach events for CV disease awareness and prevention which are in line with the CV Service Line mission.
Performs other duties as assigned
Complies with all Wellstar Health System policies, standards of work, and code of conduct.