Quality Improvement RN

The Quality Improvement (QI) RN is responsible for managing hospital-wide activities related to continuous improvement of clinical quality outcomes. Serving to support leadership at an entity level to achieve the hospital’s strategic objectives in quality, regulatory, patient safety, and pay-for-performance programs. Responsible for data gathering, analysis, and reporting of quality processes and outcomes. Acts as a role model and coach in creating a culture of safety and quality throughout the organization. Works with others of the healthcare team to coordinate a consistent strategy of comprehensive patient-centered care. 

This position independently researches, audits, and abstracts data from hospital electronic systems and other outside systems and/or platforms as needed. The QI RN uses internal and external software to compile data and complies with all hospital policies and procedures as well as CMS requirements. 

QUALIFICATIONS/REQUIREMENTS

• Healthcare experience preferred.
• Clinical experience preferred and RN license required. 
• Understanding of the use of data and basic statistical understanding with the ability to interpret data, develop reports and collaborate on developing action plans to achieve necessary changes. 
• Skilled in human relations and ability to communicate with and to deal constructively with all levels of staff, including front line, providers, and senior leaders, as well as patients and families. 
• Strong familiarity with computer programs and able to learn new platforms with relative ease. Microsoft Word, Outlook, and Excel skills required; EMR and Power Point experience preferred. 
• Demonstrates initiative, flexibility, and integrity. 
• The ability to work both independently and in a collaborative environment is essential. 
• Strong, professional organizational and interpersonal communication skills, both verbal and written.

GENERAL

• Perform assigned tasks in a confidential manner for the Quality Department. 
• Creates and prepares visual aids and reference material for staff as appropriate pertaining to quality, risk, and safety. 
• Research and retrieve material for policies, procedures, education, and system studies.
• Completes special projects assigned by the Quality Supervisor/Chief Quality and Nursing Officer.
• Coordinate with Quality leaders to schedule meetings, including time and location. Send attendee notification as needed. Start meetings via zoom and/or other platforms as indicated. Maintain attendance and minutes as specified.
• Organize/lead meetings as assigned.
• Prepare credential letters and associated variance (Q-statim) reports.
• Assist with management of complaints/grievances as assigned.
• Assist with Risk Management duties as assigned and collection of needed documents.
• Assist with Employee Health duties such as vaccinations and fit testing.

DATA MANAGEMENT

• Chart reviews/audits, conducting studies and preparing statistical data for assessment.
• Complete reviews/audits and maintain records for patient safety related topics.
• Assist with managing department triggers for case review. Assist with coordinating completion of external case reviews as needed. 
• Trend variances and report findings to department leaders. 
• Assist providers, managers, and staff in responding to variances and complaints. 
• Prepare Quality and patient safety reports as needed.
• Abstract core measures and report failures to appropriate department leaders. Submit to regulatory bodies as indicated to meet required timelines. 
• Gather and submit data to approved quality programs by deadlines. 
• Data related tasks include completing reports, updating logs/spreadsheets, conducting data specific chart audits, completing monthly dashboards for nursing departments. 

QUALITY MANAGEMENT

• Assist Quality with preparation and presentation of education programs and orientation presented by the Quality Department. 
• Assist with research, development, and implementation of policies and procedures. 
• In conjunction with the Quality Department, assist in maintaining CMS survey readiness.
• Provide leadership within scope of responsibility such as regulatory, patient safety, patient experience, and others to establish appropriate priorities and resources to achieve expected outcomes. 
• Summarize findings of the AHRQ Culture of Patient Safety Survey biennially.
• Track and report on Patient Satisfaction survey reports. 
• Active member on committees as assigned. Committee lead as assigned and appropriate. 
• Represent the Quality Department on hospital committees as needed. 
• Coordinate follow up, tracking/record keeping, and writing of grievance letters. 
• Participate in and provide oversight with various pay-for-performance programs as defined by administration as needed. This includes, but is not limited to: QHIP, MBQIP, MIPS. 
• Annually collaborate on preparation of Quality Assurance / Performance Improvement (QAPI) Plan and Periodic Review & Evaluation of Services. 
• In coordination with Quality, identify and report all Sentinel Events (SE) and ensure a Root Cause Analysis (RCA) is conducted. Facilitate and participate in RCAs as needed. Maintain a record of all SEs and RCAs and ensure action items are completed.
• Promote effective understanding of quality initiatives by being knowledgeable about various programs in which the organization participates.
• Work with Quality to prioritize NQF safe practice goals for the hospital through the evaluation of variances, complaints, QHIP, and Patient Safety survey, etc.
• Performs other duties as requested/assigned.