Quality Nurse Specialist (RN)

ECU Health • Greenville, NC

3d • Onsite

About The Position

The Quality Nurse Specialist (RN) at ECU Health Medical Center is responsible for applying improvement methods to achieve successful outcomes in quality improvement projects. This role promotes the use of improvement methods and science throughout the organization, supports a standard improvement method, and coaches others on its implementation. The specialist synthesizes information from various resources to demonstrate current practice, identifies opportunities for improvement, and analyzes data from disparate sources, including comparative data, benchmarks, and evidence-based practices. They demonstrate expertise in analytical and statistical tools, communicate improvement priorities and results using visual and narrative tools, and design project plans incorporating change management principles. A key aspect of the role is promoting a safety culture and infrastructure, applying methods to identify and evaluate risks for harm, and advancing patient/person and family-centered strategies. The specialist also demonstrates knowledge of applicable healthcare regulations and standards, guides practice and operations with these regulations, provides oversight for surveys, and facilitates the development and monitoring of action plans for non-compliant findings. They advance a continuous readiness culture, apply knowledge of professional practice evaluations (OPPE/FPPE), communicate accountability and reporting requirements, manage performance improvement opportunities, and demonstrate knowledge of healthcare payment models and their impact on quality measurement and improvement programs. The role involves analyzing the appropriate utilization of healthcare services and monitoring the impact of value-based payment initiatives and quality reporting. The specialist is expected to manage their individual work independently, demonstrate self-direction, assist with department oversight through peer coaching and mentoring, help lead goal and strategy development, identify improvement opportunities, lead improvement projects, promote collaboration, and assume leadership responsibilities within the organization. They build effective relationships and collaborations with staff and management to promote continued learning and support. Accountability includes accepting responsibility for actions and decisions, acknowledging and correcting mistakes, following through on assignments, paying attention to details, completing work thoroughly, and staying current with best practice standards, guidelines, regulatory standards, and local/state/federal laws. The role is accountable for an effective program.

Requirements

• Master's degree in applicable field or higher is required.
• Active RN license is required.
• Must have 5 years or more experience in healthcare field.

Nice To Haves

• Certification in specialty preferred within 3 years and maintained thereafter.

Responsibilities

• Synthesize information from relevant resources to demonstrate current practice and identify opportunities for improvement.
• Identify sources of valid and reliable information and metrics to monitor performance trends.
• Analyze information from disparate sources.
• Analyze comparative data, benchmarks, and evidence-based practices for possible adaptation into the organization.
• Use valid and reliable data to support opportunity recommendations and illuminate key trends for stakeholders.
• Design solutions to address opportunities based on benchmarks, goal comparison, data analysis, and correction actions.
• Advise on future data and information needs and resources to better support improvement initiatives.
• Demonstrate expertise in the use of analytical and statistical tools and techniques including understanding of how process goals are established, measured and monitored.
• Apply techniques and tools to identify variation and its causes.
• Analyze input variable to identify critical factors that must be addressed to achieve optimal process performance.
• Train others to apply analytical and statistical methods.
• Communicate improvement priorities and results using narrative and visual tools by create graphs and charts that accurately reflect valid interpretation of findings.
• Develop dashboards and scorecards to depict internal metrics and benchmark comparisons.
• Create written and verbal communication to tell a story appropriate to the audience.
• Develop system-wide dashboards and scorecards incorporating clinical and business metrics to strategic or operational goals.
• Design and develop project plans including providing project coordination using project management tool, measurement plan, estimate costs to determine budget, incorporates evidence-based guidelines.
• Use change management principles.
• Communicates project progress to all stakeholders through the project.
• Train process owners, team members, and sponsors on implementation action/measurement plans.
• Promote a safety culture and infrastructure by engaging stakeholders to understand all perspectives when addressing patient safety issues.
• Model behaviors that promotes a safety culture.
• Educate staff.
• Support adoption of high reliability principles.
• Coach staff and leaders on those principles.
• Design sustainable actions to improve patient safety.
• Build cohesive patient safety program that includes evidence-based practices.
• Apply methods to identify and evaluate risks for harm by using assessment tools and methods appropriate for identification of potential and actual patient safety risks including RCA and FMEA.
• Conducts fact-based investigations.
• Monitors actions to prevent recurrence.
• Uses improvement methods to improve patient safety reporting and processes.
• Collaborates with risk, legal, senior leadership and regulatory as appropriate.
• Establishes proactive processes, policies and educational programs to improve patient safety program.
• Advance patient/person and family-centered strategies that enhance safety and quality by promoting and encouraging opportunities for patient/family engagement.
• Incorporating patient/family feedback into improvement plans.
• Engage patients and providers in partnerships to improvement understanding and promote better collaboration.
• Demonstrate knowledge of regulations and standards applicable to healthcare setting including remain current on changes in standards and regulations.
• Evaluates regulations using authoritative interpretive resources.
• Provides expert analysis to synthesize regulations and interpretive guidance to articulate intent and value of regulations.
• Interpret new regulations and their impact in collaboration with relevant stakeholders.
• Develop processes to keep the organization aware of upcoming changes in regulations and standards.
• Guide practice and operations with applicable regulations or standards by assessing policies and practice and conduct audits to ensure compliance.
• Utilize education techniques (such as just-in-time training) during audits to enhance knowledge and understanding of standards with front-line staff.
• Provide analysis of compliance to assist with development of sustainable action plan in partnership with leadership.
• Develop process for early identification of areas that are not in compliance.
• Communicate results to leadership as an action plan for compliance.
• Provide education on regulations and standards to stakeholders.
• Provide oversight for planned and unannounced surveys including presurvey, onsite survey, and post survey activities.
• Oversee infrastructure for onsite visits.
• Analyze overall reports by prioritizing them by severity and risk to communicate findings.
• Prepare executive summaries based on identified key trends of findings.
• Oversee coordination, submission and monitoring of corrective action plans.
• Monitor intracycle activities to ensure the submission of ongoing reporting requirements per defined time periods.
• Facilitate the development and monitoring of action plans for noncompliant findings including assisting with the preparation of an action plan in response to survey or audit reports.
• Develop data collection tools for auditing/monitoring measures of success/compliance with standards.
• Develop methods for communicating action plans and results to key leaders and stakeholders.
• Analyze action plans to validate their effectiveness.
• Advance a continuous readiness culture by leading in readiness activities.
• Integrate continuous readiness activities into everyday workflows.
• Conduct continuous readiness rounding and tracers.
• Provide training and education.
• Facilitate presentations for leaders and medical staff.
• Implement/develop program to promote continuous readiness in everyday workflow.
• Apply knowledge of ongoing professional practice evaluation, focused professional practice evaluation, and requisite structures and processes including applying applicable regulations and standards to OPPE and FPPE work.
• Coordinating reviews for OPPE and FPPE processes.
• Develop processes to support practitioner practice reviews.
• Incorporate evidence based practices into OPPE and FPPE.
• Collaborate with practitioner leaders to established structure and processes.
• Engage clinical leadership by providing consultations on concerns for review, follow up, and action plans.
• Communicate accountability and reporting requirements and organization impact to internal and external stakeholders including defining stakeholders.
• Develop method or plan to disseminate information.
• Clarify expectations and accountability for creating action plans.
• Monitor action plans.
• Synthesize requirements from multiple regulatory and/or payer agencies and communicate organizational impact.
• Manage performance improvement opportunities from accountability reports and ensure follow-through including design process to monitor and trend internally and externally reported data.
• Apply improvement tools to areas of opportunities.
• Assist with action plan development.
• Monitor action plans across organization.
• Share best practices.
• Demonstrate knowledge of the impact of healthcare payment models as they apply to quality measurement and improvement programs including recognize evolving types of payment models and associated measures.
• Assess financial impact to organization.
• Educate teams on payment models and cost management.
• Communicate impact of quality initiatives on payment and cost management.
• Collaborate with stakeholders to improve cost recovery.
• Analyze the appropriate utilization of healthcare services including apply evidence-based criteria along with regulatory and payer requirements to ensure applicable standards of care met.
• Use tools to analyze quality outcomes based on reimbursement criteria.
• Apply risk assessment methods in identifying optimal care processes and outcomes.
• Prepare provider-specific utilization reports with benchmarking of internal and external peers.
• Collaborate with providers to ensure complete and timely documentation to maximize payment and minimize details.
• Apply organization specific risk calculations when analyzing the utilization of services.
• Communicate the impact of quality initiatives on payment and cost management.
• Collaborate with stakeholders to improve cost recovery for healthcare entities and providers.
• Present data demonstrating patterns and trends for quality measures.
• Collaborate with appropriate stakeholders regarding participation in alternative payment models.
• Participate in the payment control process.
• Develop improvement plans including performance metrics in collaboration with finance, operations, clinical leadership and other key stakeholders.
• Integrate mitigation plans with improvement plans to address barriers or challenges to implementation of change management/real-time actions.
• Monitor the impact of value-based payment initiatives and quality report cares including use data analytics tools to measure baseline and set target goals.
• Apply appropriate principles of risk stratification models.
• Assess physician practitioner performance data ratings with measurement of reimbursement impact.
• Utilize public and private comparative data to improve patient care.
• Recognize the relationship of clinical documentation to quality scorecards and outcome.
• Use predictive analytic models to identify potential risk factors.
• Identify potential interventions to drive breakthrough improvement.
• Assess revenue impacts associated with organizational quality performance.
• Develop organization-specific key performance indicators on scorecard.
• Present information to stakeholders regarding value of complete and accurate clinical documentation, patient management, and accountability.
• Independently manages individual work.
• Demonstrates self-direction in area of assigned responsibility.
• Assists with department oversight to include peer coaching and mentoring.
• Helps lead the development of goals and strategies.
• Identifies improvement opportunities and leads improvement projects.
• Actively promotes collaboration and seeks to learn from others.
• Demonstrates ability and willingness to assume leadership responsibilities with the organization.
• Build effective relationships and collaborations with front-line staff and management to promote continued learning and support.
• Accepts responsibility for actions and decisions.
• Acknowledges and corrects own mistakes.
• Follows through on assignments, projects, or requests.
• Pays attention to details.
• Completes work, which is thorough and accomplishes desired results.
• Stays current with best practice standards, guidelines, regulatory standards, and local/state/federal laws.
• Accountable for an effective program.

Benefits

• Offers of employment are subject to successful completion of all pre-employment screenings, which may include an occupational health screening, criminal record check, education, reference, and licensure verification.

What This Job Offers

• Job Type: Full-time
• Career Level: Senior