Pediatric RN - Quality Improvement

University Hospitals•Cleveland, OH

About The Position

The Improvement Nurse serves as a strategic partner, responsible for facilitating on behalf of the Quality Institute, the assigned facility and/or the assigned market improvement initiatives that target one or more system priorities including the development of the scope, design, implementation, control, and validation of the initiatives outcome results. The Improvement RN may be responsible for developing and leading improvement activities at the entity and system level in the following areas:

Requirements

Bachelor's Degree in Nursing or Healthcare related field (Required)
Educational degree for Nursing Licensure (e.g. Diploma, Associates, or Bachelors) (Required)
3+ years Acute care clinical experience or closely related healthcare experience (Required)
Excellent interpersonal communication skills (Required proficiency)
Ability to teach and mentor (Required proficiency)
Ability to lead small teams effectively (Required proficiency)
Strong presentation skills (Required proficiency)
Computer skills in all Office applications, including excel. (Required proficiency)
Knowledge of Process improvement modalities. (Required proficiency)
Registered Nurse (RN), Ohio and/or Multi State Compact License (Required)

Nice To Haves

Quality & Process Improvement skills (Preferred proficiency)
Related certification (e.g. CPHQ, Green Belt, CPHRM) (Preferred)

Responsibilities

Review care of patients (concurrent and retrospective) to assess for complications of care and adherence to published practice standards
Liaison with the physicians, nurses and ancillary staff regarding Quality and Patient Safety, and other quality/risk initiatives, including publically reported indicators
Develops performance improvement activities as defined by organizational priorities
Attends departmental meetings, as assigned, to serve as Quality Institute representative and subject matter expert.
Performs tracer activity to assure compliance with all regulatory standards.
Serves as coach and mentor to staff regarding regulatory and other initiatives defined in Quality & Safety priorities
Communicates opportunities for improvement to unit/departmental leadership as identified.
Facilitates communication with leadership on organizational opportunities for improvement at unit or department level
Collaborates with Manager and Quality Institute Leadership in identifying annual priorities as it impacts Patient Safety
Supports an effective Patient Safety Program for this facility based on the current priorities
Participates in Performance Improvement activity related initiatives to positively impact Patient Safety and Reduction of Adverse Events
Assists in identifying best practices and process redesign to improve patient safety
Assists with organization wide continuous accreditation readiness and continuous regulatory compliance, including a proactive tracer program
Maintains data collection to support and drive accreditation functions
Actively participates in process improvement initiatives to improve compliance with accreditation standards
Under direction of manager / administrator disseminates data and feedback on compliance with accreditation standards to all stakeholders
Participates with UH Accreditation team to enhance monitoring, promote needed practice changes and improve compliance system wide.
Is actively engaged in review of updates to accreditation standards (CMS, DNV, TJC, & Specialty) and timely communication of changes to involved stakeholders.
Under the direction of manager, shares regulatory (DNV/TJC/ODH/CMS) communications. Provides feedback as required to DNV/TJC via secure site.
Perform infection surveillance, analysis, interpretation and reporting of hospital acquired infections (HAIs)
Act as a resource for Employee Health program working collaboratively to review and investigate potential employee Infection Control Issues and maintain compliance with federal, state and city health codes, regulations and agencies including the Ohio Department of Health, OSHA and CMS
Monitor and analyze patient care practices. Actively participate in infection reduction initiatives in order to prevent and reduce HAIs
Conduct education and ongoing in-service programs for multi-disciplinary health care teams
Assure compliance with policy and procedure to ensure standards that meet DNV, TJC, OSHA, CMS, ODH, CDC standards, recommendations and requirements Maintain knowledge of current guidelines, regulations and best practices relating to infection prevention
In collaboration with the hospital’s Infectious Disease physician, or IC Medical Director oversees and coordinates infection control policies, hospital Infection Control Committee, Infection Control Risk Assessment and Infection Control Plan, and Infection Control data submission (e.g. NHSN for CMS compliance and communicable disease reporting etc.)
Active membership in APIC
Performs other duties as assigned.
Complies with all policies and standards.
For specific duties and responsibilities, refer to documentation provided by the department during orientation.
Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.