Job Facility: University of Maryland Medical Center
Employment Type: Full Time
What You Will Do:
General Summary Under limited supervision, plans, coordinates, leads, and monitors quality improvement and patient safety initiatives for clinical service departments and across the organization. Accountable for overall quality of care provided to patients in the designated clinical services, as well as compliance with requirement by CMS, Joint Commission, and disease specific certifications. Collects and analyzes data, conducts presentations, provides consultation, and staffs service specific and hospital-wide committees.
Principal Responsibilities and Tasks
The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.
Plans, organizes, and directs clinical services’ (TRANSPLANT DEPT.) quality improvement and patient safety activities. Conducts studies of identified problem areas in accordance with organizational, department, and clinical service priorities.
Works collaboratively with Clinical Service Department Chairs and Quality Physicians and with staff and leaders to identify quality improvement and patient safety priorities.
Collects, reviews and analyzes data related to quality improvement and clinical care, and identifies strategies and opportunities for evidence based practice and efficiency improvements.
Meets regularly with departmental quality management physicians in order to formulate agenda for department quality management meetings; determine departmental quality focus and priorities; review data to be presented at departmental quality management meetings; and present quality issues that need review.
Initiates review of cases regarding patient care quality, safety, and compliance issues, making recommendations to physicians, department managers, administration and committees for corrective actions.
Reviews incidence reporting including near miss events for clinical services; facilitates appropriate action planning, and evaluates action plans as required.
Maintains and assures accuracy of departmental dashboards in collaboration with Clinical Decision Support Department and the Data Scientist. Prepares statistical reports as required for medical staff, quality management committees and quality task forces to identify trends or patterns that present an opportunity to improve the quality and safety of patient care.
Facilitates clinical review and problem-solving processes through the use of quality improvement methodology and tools, to include Root Cause Analysis (RCA), Plan Do Check Act (PDSA), and Lean methods.
Leads and coordinates special quality improvement projects and studies. Identifies resources needed, persons to be involved and project management aspects of accomplishing the project. Participates in improvement collaborative with external organizations when opportunities arise. Responsible for assuring monitoring of action plans in order to sustain improvements.
Leads, coordinates, and supports organization-wide quality and safety improvement activities. Facilitates multidisciplinary teams using improvement tools to achieve improved quality care.
Provide leadership in the development and implementation of departmental strategies regarding regulatory compliance.
Participates and assists with organizational visits from accrediting agencies.
Participates in organization-wide Joint Commission tracers, monitoring and educating staff in regulatory compliance and hospital policy requirements
Oversees reviews and actions taken in response to recommendations for improvement and deficiencies identified by regulatory agencies and by patient complaints.
Works with providers to monitor and promote quality improvement activities related to clinical documentation in the medical record.
Provides consultation to ancillary support and clinical departments within the Medical System to establish quality indicators, analyze quality and utilization data, identify trends/patterns and formulate plans for resolving issues/problems.
What You Need to Be Successful:
Education and Experience
Bachelor’s degree in Nursing, or an equivalent combination of education and experience, is required. Master’s Degree preferred.
Current licensure as a Registered Nurse in the State of Maryland is required.
Three (3) years of progressively responsible professional experience performing quality management activities, or equivalent, is required.
Knowledge, Skills and Abilities
Demonstrated broad based knowledge of improvement methodology and ability to coach staff. Ability to facilitate clinical quality improvement and the problem-solving process in a clinical setting.
Proficiency in monitoring, evaluating and motivating the performance of professional staff.
Knowledge of state and federal regulations, and The Joint Commission standards and practices for acute care hospitals is required. Knowledge of Departmental of Health and Mental Hygiene (DHMH) for state licensure and Medical conditions of participation. Knowledge of quality improvement and risk management is required. Familiarity with physician practice standards, and legal and ethical practices
Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care.
Ability to assess safety, quality, and regulatory compliance problems, recommend solutions, and resolve issues in a timely, efficient, and effective manner.
Ensures patient safety in the performance of job functions and through participation in hospital, department or unit patient safety initiatives.
Takes action to correct observed risks to patient safety.
Reports adverse events and near misses to appropriate management authority.
Identifies possible risks in processes, procedures, devices and communicates the same to those in charge.