Coord, Quality & Performance Improvement - UH Quality & Safety Management - University Hospital

Responsibilities

• Abides by and enforces all compliance requirements and policies and performs these responsibilities in an ethical manner consistent with the organization's values.
• Adheres to hospital policies including confidentiality.
• Works the assigned schedule and overtime as needed.
• Enhances professional growth and development through participation in education programs.
• Engages and fosters relationships with all levels of staff within the organization; building strong relationships with team members, faculty and customers.
• Possesses superior time management skills with the ability to multi-task and prioritize, establish timelines and meet deadlines.
• Ensures on-time completion of deliverables; highly organized and skilled at managing numerous details for multiple projects.
• Showcases an open mind and spirit to continuous learning and research.
• PRACTICES innovation in process improvement and exhibits passion in the belief of harm prevention and evidence-based practice.
• Maintains a spirit of optimism and conviction to speak up for quality and safety, showcasing constructive approaches to errors and system improvement opportunities.
• Advocates for the engagement of the family and patient.
• Communicates and demonstrates appropriate customer relation skills with physicians, patients, families and co-workers.
• Maintains accurate, complete & confidential information utilized in the hospital Quality Assurance and Performance Improvement program.
• Serves as a leader or member of various committees.
• Advises organizational leaders, department heads in planning, monitoring and evaluation activities.
• Applies knowledge of performance improvement tools to assist teams, helping to manage and propel team communications.
• Provides education/information on Performance Improvement activities to various healthcare audiences on a regular basis.
• Serves as a subject matter expert in the concepts of quality management, performance improvement, and patient/family engagement.
• Possesses ability to accurately process detail-oriented work with advanced problem-solving skills, ability to think quickly and implement plans/structure for accomplishing work, remaining composed under pressure, working in a small, fast moving, and at times, intense environment.
• Anticipates team needs and takes initiative to complete work before being asked.
• Applies strategic planning to address large scale opportunities for improvement with transformational leadership.
• Evaluates and analyzes complex data using statistical analysis to identify opportunities for improvement.
• Understands the principles of human factors and safety and applies them in performance improvement project designs.
• Participates in root cause and system analysis of sentinel, adverse, or near miss occurrences to discern improvement opportunities, as needed.
• Coordinates and promotes initiatives in alignment with the Joint Commission National Patient Safety Goals, reduction or elimination of patient harm, and evidence-based quality initiatives.
• Assists the organization in identifying opportunities for improvement.
• Identifies opportunities for improvement in documentation and initiates improvement strategies.
• Develops staff education related to quality and performance improvement initiatives.
• Recommends and uses effective methods to spread quality management and improvement knowledge materials/concepts, meaningful and relevant for organizational needs.
• Plans, collects, organizes and reports QA data for use in the PI program and in external and internal benchmarking programs according to the hospital’s Pl Plan.
• Prepares reports, attends, and presents committee meeting materials.
• Assists the organization in identifying opportunities for improvement.
• Serves as a subject matter expert in the concepts of quality management, performance improvement, and patient/family engagement.
• Facilitates PI activities.
• Collaborates with clinical areas to ensure that care meets evidence-based standards.
• Designs and facilitates revisions or builds in Cemer applications to support evidence-based care.
• Participates in local, state and or national activities pertaining to evidence-based care.
• Validates data in the various programs as needed.
• Facilitate
• Participates in activities to ensure that policies/measures, safe practices are being followed.
• Conducts inter rater reliability audits for the program as indicated.
• Conducts Plan-Do-Study-Act (PDSA) cycles for small, rapid-cycle tests of change.
• Seeks engagement of all staff, medical staff and residents in performance improvement initiatives.
• Maintains current knowledge of Joint Commission/CMS standards, regulatory requirements.
• Collaborates in the development of departmental and organizational Pl dashboards.
• Communicates and uses appropriate customer relation skills with physicians, patients, families and healthcare team in person and via telephone.
• Communicates relevant aspects of evidence-based standards and compliance to members of the health care team and medical staff committees.
• Demonstrates excellent interpersonal verbal skills and writing skills.
• Maintains accurate and complete records through documentation.
• Advanced skills and working knowledge of Microsoft Word, Excel, and PowerPoint.
• Uses internet, email, databases, spreadsheets, word processing and presentation programs.
• Accepts and completes all duties positively and without conflict.
• Cooperates, helps others and improves the performance of the department.
• Completes all mandatory unit, educational and hospital requirements.
• Utilizes cost effective practices in performing all aspects of the job.
• Completes all mandatory department, educational and hospital requirements.
• Adheres to current Infection Control and Safety Standards.
• Regular and prompt attendance.
• Able to work schedule as defined and overtime as required.

Qualifications

• Bachelor's Degree in nursing from an accredited institution and 5 years of professional nursing experience
• Master's Degree in nursing
• Preferred: Certification in IHI's model for improvement, Six Sigma, Lean or CPHQ
• Comparable combination of education and experience may substitute for the above requirements.