Quality and Safety Excellence Nurse

Trinity Health•Davenport, IA

5d•Onsite

About The Position

The purpose of the Quality & Safety Excellence Nurse is to assist and support the manager in quality and safety strategies, plans, and regulatory requirements that improve outcomes and reduce harm to patients. The individual works closely with ministry colleagues, providers, and leaders in implementing, monitoring, and evaluating quality and safety programs, structures and requirements that culminate in high reliability. The Quality & Safety Excellence nurse, under the direction of the manager, assists in achieving excellence in quality and safety work related to patient outcomes (process and outcome measures), performance improvement strategies and methodologies, culture of safety (TogetherSafe) initiatives, and patient safety organization (PSO) collaboration with risk management that ensures high quality and safe care. Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) Mission, Vision, Core Values, Actions and Promise in behaviors, practices, and decisions. Identifies patient quality and safety issues/concerns and collaborates with key stakeholders to address and improve. Coaches for problem solving to improve quantitative and qualitative clinical outcomes and patient experience. Service-aligned role to facilitate the integration of clinical quality indicators into the work environment. Conducts review of medical records for data related to quality and safety initiatives required by CMS, The Joint Commission, and others as assigned. Supports Nurse Governance Council as appropriate to quality and safety work. Assists with TJC Survey as applicable. Utilizes vendor database, or other computer program, to input, aggregate and analyze data for quality measurement directed towards improvement of organizational performance, as assigned. Reports outcomes of measures to appropriate clinical leaders, medical staff, disease management groups and others as identified. Educates physicians and clinical staff regarding requirements (by CMS, The Joint Commission and others) for specifications and documentation expectations for assigned quality and safety measures. Works with multi-disciplinary team to ensure measure documentation is within required specifications. Creates reports, scorecards and graphs necessary to communicate analysis of data. Collaborates with multi-disciplinary teams to develop strategies for variance reduction and performance improvement activities. Facilitates improvement work related to quality and safety that may include falls prevention, readmissions, mortality, and other projects determined by manager. Demonstrates knowledge, skills and abilities to perform quality improvement activities and medical record chart abstractions to include, but not limited to: CMS core measures, Trinity Health measures, NDNQI measures, ORYX measures, medical staff measures, and selected measures related to data collection for national data bases. Accurately interprets clinical information in the medical record including, but not limited to physician documentation, diagnostic tests, medications, procedures, and nursing assessments. Actively participates in the quality improvement meetings as scheduled. Reports successes and deficiencies related to selected indicators. Participates in action planning and follow-up to improve patient care and services. Attends and participates in Trinity Health’s monthly Quality Contacts call, and applies information to current quality activities. Participates in periodic CMS or audio conference calls, WebEx education, and other Internet communications related to CMS indicator manual revisions and other updates. Participates on the Nursing Performance Improvement Committee, and other hospital committees. Analyzes and interprets information to ensure requesters receive reports that are accurate, valid and reliable, and displayed in a useable and meaningful way to include usage of a variety of statistical and performance improvement tools. Provides medical staff support as determined by manager. Other duties as assigned.

Requirements

Bachelor’s degree in nursing, or higher preferred
Current RN license to practice nursing in Iowa where work is performed
Minimum of three (3) years of experience in a healthcare setting.

Nice To Haves

Previous hospital performance improvement experience preferred.

Responsibilities

Assist and support the manager in quality and safety strategies, plans, and regulatory requirements.
Implement, monitor, and evaluate quality and safety programs, structures, and requirements.
Identify patient quality and safety issues/concerns and collaborate with stakeholders to address them.
Coach for problem-solving to improve clinical outcomes and patient experience.
Conduct reviews of medical records for data related to quality and safety initiatives.
Support the Nurse Governance Council.
Assist with TJC Surveys.
Input, aggregate, and analyze data for quality measurement using vendor databases or other computer programs.
Report outcomes of measures to appropriate clinical leaders, medical staff, and disease management groups.
Educate physicians and clinical staff regarding requirements for quality and safety measures.
Work with multi-disciplinary teams to ensure measure documentation is within required specifications.
Create reports, scorecards, and graphs to communicate data analysis.
Collaborate with multi-disciplinary teams to develop strategies for variance reduction and performance improvement.
Facilitate improvement work related to quality and safety, including falls prevention, readmissions, and mortality.
Perform quality improvement activities and medical record chart abstractions.
Interpret clinical information in the medical record.
Participate in quality improvement meetings.
Report successes and deficiencies related to selected indicators.
Participate in action planning and follow-up to improve patient care and services.
Attend and participate in Trinity Health’s monthly Quality Contacts call.
Participate in CMS or audio conference calls, WebEx education, and other Internet communications related to CMS indicator manual revisions and updates.
Participate on the Nursing Performance Improvement Committee and other hospital committees.
Analyze and interpret information to ensure accurate, valid, and reliable reports.
Provide medical staff support as determined by manager.
Perform other duties as assigned.