Nursing Quality Management Specialist 2 - Full Time

Primary Responsibilities for Quality Hospital Accreditation

• Lead assigned accreditation readiness activities for internal mock-surveys, and required accreditation activities.
• Ensure a continuous readiness in collaboration with healthcare quality colleagues and management, within assigned area of responsibility, and in close collaboration with Director, Quality Management for Hospital Accreditation.
• Manage the establishment, compliance, and policy and procedure evaluation of the assigned accreditation functions.
• Conduct reviews of the effectiveness of the Quality Management Plan and related Policies and Procedures, and reviews and revises the Plan, its Program Goals and Objectives, and all related Policies and Procedures as necessary.
• Participate in the development of, and continuously monitor, an internal reporting structure for quality management and related activities under the direction of senior management.
• Ensures the timely reporting of quality data to appropriate individuals through a systematic and defined multidisciplinary process.
• Assist committees and departments with PI planning, organization, design of monitoring systems, implementation of study topics and follow-up activity, as necessary.
• Collaborates with Risk Management, Regulatory Compliance, Healthcare Quality, and Environment of Care Safety Officer in the identification of opportunities for improvement in the areas of clinical quality and patient safety.
• Manages the timely submission of patient care data for patient satisfaction and TJC.
• Analyzes findings and implements appropriate interventions to demonstrate improvements in quality outcomes.
• Ensures accuracy and validation of unit’s work product and submissions, ensure deadlines are met, and provide effective coaching and training to collaborators in order to successfully meet established standards of excellence and metrics.
• Maintains knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals and hospital-based clinics, including but not limited to TJC, CMS, AHCA, Commission on Cancer, and professional nursing standards.

Qualifications

• Education: Minimum Bachelor’s Degree in Nursing, Health Science, Public Health, Health Informatics or a related health care field.
• Certification and Licensing: Minimum State of Florida Practical Nurse (LPN) or Registered Nurse (RN); or ability to obtain a Florida licensure by endorsement in first six months of position start date. Clinical licensure must be kept clear and active for duration of employment.
• Basic Life Support (BLS)
• Experience: Minimum of 4 years’ experience (comprised of at least 2 years clinical nurse work experience in a clinical or healthcare environment AND at least 2 years direct experience managing clinical quality outcomes involving accreditation and/or quality assurance activities, inclusive of a service lines or a disease specific group).
• Proficiency with Microsoft Office Suite programs, Excel, PowerPoint, Word.
• Working knowledge of accreditation, regulatory, licensing and other standards, requirements, and guidelines applicable to hospitals and hospital-based clinics, including but not limited to TJC, CMS, AHCA, Commission on Cancer, and professional nursing standards.
• Preference given to any combination of the following experiences: Coursework, continuing education completion of quality and patient safety, clinical informatics, patient centered outcomes, quality improvement, and related topics.
• Acute care experience, in clinical specialty, within the last two years.
• National Certification in area of clinical specialty.
• Familiar with aspects of care, standards of care metrics for accreditation and maintenance.
• Experience with EpicCare Ambulatory Core EMR (EpicCare Ambulatory, Care Everywhere, MyChart, Workbench).
• Previous working experience with any of the following programs preferred: Sequel, ProDiver, Care Discovery, Tableau, NetAccess, Cerner, Sovera and/or Vizio.
• Experience with spreadsheets and database software.
• Evidence of ability to draw on knowledge from the following areas: Measurement of patient needs and nursing workload, continuous process improvement processes, performance improvement, service excellence, systems for patient safety, healthcare quality.
• Knowledge of the principles and practices of value-based care, including familiarity with barriers to high-value care.
• Knowledge of the principals and practices of value-based decision-making, health care payment / reimbursement, and delivery models.
• Knowledge, Skills and Behaviors: Commitment to University Values: Diversity, Integrity, Responsibility, Excellence, Compassion, Creativity, Teamwork.
• Demonstrated competency in computer applications, inclusive of the ability to learn new applications and programs; excellent typing skills.
• Professionalism: Ability to incorporate national professional organization as well as business unit and health system’s goals to improve patient safety and quality outcomes.
• Excellent interpersonal skills: Ability promote and sustain outstanding interpersonal and customer service skills (verbal and written) while accepting responsibility to ensure all working relationships are respectful and professional.
• Excellent critical thinking skills: Ability to consistently apply independent and critical thinking skills to solve problems and escalate problems.
• Ability to be self-directed while successfully managing the prioritization and execution of multiple deadline-driven projects simultaneously.
• Excellent attention to detail: Demonstrated ability to accurately review, screen and enter data.
• Excellent communication and presentation skills: Ability to clearly, effectively, and respectfully communicate questions, ideas, and solutions verbally and in writing to a broad spectrum of specialized skill and clinical experience.
• Ability to conform to shifting priorities, demands, and timelines through analytical and problem solving capabilities.
• Ability to ensure consistent and accurate adherence to established workflows and processes.
• Required ability to sustain mature judgement and maintain strict confidential information and patient confidentiality as mandated by HIPAA, and University policies, respect the rights and privacy of others at all times.
• Required to maintain current knowledge and practice in compliance with standards established by external regulatory agencies that impact job performance and deliverables, and maintain active licenses / certifications as deemed required by minimum requirements for position, e.g., maintain sufficient knowledge of TJC, Federal and State regulations and PRO activities to ensure hospital and medical staff activities are in compliance with regulations.