Quality & Patient Safety Specialist

HealthEast Care System•St Paul, MN

About The Position

Responsible for the collaborative development and implementation of a quality assessment and performance improvement program for the system. Maintains knowledge of, and complies with, all relevant laws, regulations and policies, procedures and standards. Actively participates in creating and implementing improvements to achieve clinical, satisfaction and/or efficiency outcomes. Partners with system leaders to coordinate the Quality Program and develops, implements and maintains an effective, ongoing hospital-wide, data driven quality assessment and quality improvement program. Assesses quality for the defined patient population and determine priorities for performance improvement. Provides basic support for the Clinical Councils in partnership with the physician and nursing leadership. Develops and maintains a current quality plan, develops and provides ongoing support for scorecards and data needs, reviews quality measurement data on a regular basis and to identify, prioritize and monitor improvement activities. Collaborates with leadership to analyze data from the electronic safety reporting system and develops priorities for improvement including. Reviews all events and assures accuracy with consistently applied definitions, assures events are reviewed by all involved leaders and closes event when complete. Partners with leaders and system experts around patient safety efforts. Oversees the Root Cause Analysis process (RCA), facilitates and documents event details, works with team to create robust action plans, implements changes. Completes all required processes for reporting and documentation for all reportable adverse health events. Completes mortality reviews. Identifies and reports those which require notification to regulatory agencies, reviews for quality issues and opportunities to improve Failure to Rescue and refers to appropriate leaders. Serves as the chapter expert for selected Joint Commission chapters and CMS conditions of participation, including Performance Improvement and the National Patient Safety Goals. Serves as a consultant during surveys involving the Joint Commission, CMS, MDH and other regulatory agencies. Oversees the selection and completion of required FMEA activities. Partners with leaders and the data/informatics team to design effective measurement plans. Develops and provides and ongoing support for scorecards and data needs, reviews quality measurement data on a regular basis and to identify, prioritize and monitor improvement activities. Prepares analysis of clinical data, including the identification and abstraction of appropriate data. Serves as the subject matter expert for the functionality of the electronic event software suite.

Requirements

3 to 5 years nursing experience required in a clinical setting.
Experience in Quality, Performance Improvement and working with regulatory requirements.
Experience in working with physicians, leaders and staff.
Experience in leading multidisciplinary teams.
Experience in accreditation/regulatory surveys.
Extensive experience in Quality, Performance Improvement, Data abstraction and interpretation, Software management, and regulatory requirements.
Knowledge of quality and improvement principles, tools and methods.
Knowledge of regulatory requirements, including Joint Commission and CMS.
Skills in Microsoft Word, Excel and PowerPoint.
Data management skills.
Clinical knowledge base with review and assessment of clinical records and data.
Evidence-Based Practice knowledge and skills.

Responsibilities

Collaborative development and implementation of a quality assessment and performance improvement program for the system.
Maintain knowledge of, and compliance with, all relevant laws, regulations, policies, procedures, and standards.
Actively participate in creating and implementing improvements to achieve clinical, satisfaction, and/or efficiency outcomes.
Partner with system leaders to coordinate the Quality Program.
Develop, implement, and maintain an effective, ongoing hospital-wide, data-driven quality assessment and quality improvement program.
Assess quality for the defined patient population and determine priorities for performance improvement.
Provide basic support for the Clinical Councils in partnership with physician and nursing leadership.
Develop and maintain a current quality plan.
Develop and provide ongoing support for scorecards and data needs.
Review quality measurement data on a regular basis to identify, prioritize, and monitor improvement activities.
Collaborate with leadership to analyze data from the electronic safety reporting system and develop priorities for improvement.
Review all events and assure accuracy with consistently applied definitions.
Assure events are reviewed by all involved leaders and close events when complete.
Partner with leaders and system experts around patient safety efforts.
Oversee the Root Cause Analysis process (RCA), facilitate and document event details, and work with the team to create robust action plans and implement changes.
Complete all required processes for reporting and documentation for all reportable adverse health events.
Complete mortality reviews.
Identify and report events requiring notification to regulatory agencies.
Review for quality issues and opportunities to improve Failure to Rescue and refer to appropriate leaders.
Serve as the chapter expert for selected Joint Commission chapters and CMS conditions of participation, including Performance Improvement and the National Patient Safety Goals.
Serve as a consultant during surveys involving the Joint Commission, CMS, MDH, and other regulatory agencies.
Oversee the selection and completion of required FMEA activities.
Partner with leaders and the data/informatics team to design effective measurement plans.
Prepare analysis of clinical data, including the identification and abstraction of appropriate data.
Serve as the subject matter expert for the functionality of the electronic event software suite.