ST. CHARLES HEALTH SYSTEM

JOB DESCRIPTION

TITLE:                                      Quality Improvement and Patient Safety RN

REPORTS TO POSITION:       Manager of Risk Management & Patient Safety

DEPARTMENT:                         Quality Management

DATE LAST REVIEWED:          May 3, 2023

OUR VISION:                Creating America’s healthiest community, together

OUR MISSION:             In the spirit of love and compassion, better health, better care, better value

OUR VALUES:              Accountability, Caring, Teamwork and Safety

DEPARTMENTAL SUMMARY: The Quality Management (QM) department provides essential services to St. Charles Health System (SCHS) including: quality improvement expertise and support; data analysis; regulatory affairs, accreditation and licensing expertise and support; environment of care safety programming, expertise, and support; emergency preparedness; policy and document library management and support; data abstraction; integrity of clinical documentation; the patient experience and grievance program; and risk management and patient safety program.

POSITION OVERVIEW: The Quality Improvement and Patient Safety RN (QIPS-RN) is responsible for facilitating quality improvement initiatives within their assigned service lines and committees in alignment with the organization’s True North objectives. The QIPS-RN also supports the Patient Safety program across assigned facilities and service areas within St. Charles Health System and serves as a Subject Matter Expert for Root Cause Analysis, Safety Culture, National Patient Safety Goals and other evidence-based programs as needed. The QIPS-RN works collaboratively with a diverse array of stakeholders to assist with data analysis, goal selection, process improvement, and the development of sustainment plans and develops, coordinates, and facilitates implementation of effective systems for risk identification, investigation, and mitigation of both potential and actual patient safety concerns and risks. The QIPS-RN works in close partnership with the Quality and Safety teams to meet regulatory and accreditation requirements, as well as the Lean Improvement Office to ensure that all work is approached with a Lean mindset. A successful Caregiver in this role will have the capacity to maintain focus in a fast-paced environment, while staying flexible enough to adapt to quickly changing environments and priorities.

This position does not directly manage other caregivers, however, may be asked to review and provide feedback on the work of other caregivers.

ESSENTIAL FUNCTIONS AND DUTIES:

Utilizes quality and safety improvement principles, such as PDSA and A3 thinking, to design, develop, implement and sustain True North initiatives for their respective service lines and committees.

Works collaboratively with a diverse array of Caregivers, leadership, and support services to assist with data collection, analysis, goal selection and the development of various auditing tools, such as: standard work, Epic bundles and performance scorecards.

Participates in development and maintenance of numerous quality and safety dashboards and scorecards for their respective service lines and committees.

Supports System Safety Quality Council (SSQC), Clinical Leadership Council, and other committee meetings.

Supports continuous survey readiness in coordination with Accreditation Manager including regular rounding, mock (and actual) survey participation, CAREboard support, and auditing.

Completes quality and patient safety reports as needed, including analysis of data, identification of trends, and recommendations for improvement.

Works with the Patient Safety and Risk Management Team to review Safety Alert System (SAS) reporting and response process, including severity rating and evaluation of all safety events, RCA and apparent cause analysis; Stops the line to mitigate potential patient safety conditions and maximize learning.

Uses trends obtained from safety reports, patient safety rounds and other sources of patient safety data to focus on areas for further analysis, risk management, patient safety and loss prevention activities.

Identifies potential and actual sentinel events with prompt notification and debrief to key stakeholders including senior leadership, and site administration for conducting investigation of event and root cause analysis.

Leads investigation for a Sentinel or serious harm event investigation and analysis. Leads RCA process and failure effect mode analysis (FMEA) to identify opportunities for system and process improvements. Supports the preparation of documents for reporting serious harm events to State and accreditation agencies.

Proactively performs surveillance and evaluates patient safety risks in a uniform and consistent manner for assigned facilities, service areas and affiliated joint ventures.

Provides caregiver and provider guidance and support for patient care issues with patient safety/risk or legal implications, i.e., consent issues. Works in collaboration with the compliance department for potential EMTALA and HIPAA violations.

Reviews and supports the completeness of patient complaint and grievance response letters.

Provides guidance to caregivers and providers for disclosure of unanticipated events to patient and their families.

Proactively conducts failure mode and effect analysis for high risk or problematic care processes across System facilities and joint venture businesses, at minimum as required by The Joint Commission for continued accreditation.

Collaborates with Subject Matter Experts to develop and spread learnings via Safety Alerts, Advisories, and key learnings based on bets practices and evidenced based medicine.

Supports the vision, mission and values of the organization in all respects.

Partners with the Lean Improvement Office on a variety of process improvement initiatives as indicated by project type and scope.

Supports Lean Improvement Office by functioning as a “champion of change” and consistently leading with humble inquiry to unearth quality gaps, lead improvement initiatives, create sustainment plans and monitor for variation.

Provides and maintains a safe environment for caregivers, patients and guests.

Conducts all activities with the highest standards of professionalism and confidentiality.  Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.

Delivers customer service and/or patient care in a manner that promotes goodwill, is timely, efficient and accurate. 

May perform additional duties of similar complexity within the organization, as required or assigned.

Participates in creating a healing environment that supports all aspects of the care environment and the wholeness of every patient and caregiver.

Participates in creating intentional relationships and demonstrates focus attitudes and behaviors that enhance the care experience.

Provides and maintains a safe environment for caregivers, patients and guests.

EDUCATION                 

Required:  Bachelor Science in Nursing, Registered Nurse.

Preferred: Master’s degree in nursing, public health, healthcare management, data analytics, statistics   

LICENSURE/CERTIFICATION/REGISTRATION

Required: Current RN License. Ability to travel to business functions/trainings/meetings and all St. Charles Health System worksites.

Certified Professional of Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) within 1 year of hire.

Preferred:  Lean, Lean Sig Sigma Green/Black Belt, MINT, CQIA, CQE, or other industry-recognized quality certification

EXPERIENCE

Required: Two years’ experience in healthcare field, data analytics, public health or other closely related field.         

Preferred: Two years’ experience facilitating quality improvement and safety initiatives using Lean or other process improvement framework. Experience with Joint Commission standards and other standards such as CMS and OSHA. Experience facilitating groups through complex and sensitive issues and teaching process improvement principles.  Experience working with medical staff on performance improvement. eExperience using Excel, manipulating data sets, creating pivot tables and other visual forms of data analysis.                  

PERSONAL PROTECTIVE EQUIPMENT

Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.

PHYSICAL REQUIREMENTS:

Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.

Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.

Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.

Rarely (10%):  Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.

Never (0%):  Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.

Exposure to Elemental Factors

Never (0%):  Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.

Blood-Borne Pathogen (BBP) Exposure Category

No Risk for Exposure to BBP

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