Job Code: 08621 12027
Oversees implementation and adherence to Evidence Based Care throughout the organization
Screens/reviews medical records and all other available data sources in order to collect, analyze, and display data for assigned care measures and areas of responsibility.
Leads and participates in quality and safety initiatives in collaboration with all hospital departments
Works closely with the VP, Quality/Risk and other staff to promote the best interest of the QRM Department.
Maintains an orderly system of record keeping and flow of information.
Knowledge of current disease specific guidelines and evidence based sepsis recognition and treatment
Abstracts and reports stroke criteria data for Joint Commission and State Requirements
Leads Sepsis mortality and bundle compliance3 improvement initiatives
Department Specific Criteria:
Uses process improvement tools to improve processes and poutcomes
Collects, analyzes, displays data for assigned medical staff, departments/functions accurately and timely.
Collects/Verifies data for reporting to all assigned internal/external data bases
Participates in COMET/ JC/CMS measures data collection/analysis/ verification
Serves to facilitate PI /FMEA/RCA teams as assigned.
Uses measurement and analysis with objectivity and foresight to make decisions.
Assists with collection/assembly of data for generic/risk screens.
Works with Physicians, Directors, and employees to identify opportunities to improve care/service.
Periodically reappraises plans/programs for assigned departments and committees.
Recommends changes based on opportunity to improve, changes in current literature, and effectiveness of actions.
Demonstrates ability to create, initiate, and integrate new concepts and practices to facilitate improvements.
Coordinates work with other members of the department to avoid duplication of efforts.
Reviews work load and makes necessary adjustments to meet needs of the department.
Assists the facility and medical staff with task of monitoring problematic cases and/or trends, formulating an action plan and evaluation of actions taken.
Assures that PI findings are reported through appropriate channels of the medical staff.
Keeps calendar of all activities and reports in a timely manner.
Prepares reports, minutes, supportive data in accurate, timely fashion.
Observes for any significant risk management event and reports to VP, QPS.
Shows responsibility to report significant events through electronic notification when appropriate
Prepares data for assigned medical staff members and others under credentialing by MSO for profiling/reappointment.
Keeps abreast of current Performance Improvement requirements.
Demonstrates strong knowledge and understanding of Joint Commission/CMS standards and facilitates implementation.
Keeps abreast of new federal and state requirements and other pertinent guidelines.
Coordinates evidence based Sepsis program with physicians, staff and the community
Analyzes 3 and 6 hour bundle compliance measures, identifies trends for improvement
Recommends process improvement through evidence based interventions with physician/staff input
Coordinates and provides education to physicians, staff and community on sepsis awareness and treatment
Registered Nurse with current Georgia RN license with current Georgia license
Minimum of five (5) years clinical experience and/or five (5) years of performance improvement review process
Two (2) years experience in hospital quality, patient safety or related field preferred
Last Edited: 05/02/2019
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