Quality Improvement & Patient Safety RN; Ambulatory

Position: Quality Improvement & Patient Safety RN (Ambulatory)
Salary range: $95,139 - $130,811 annually, based on qualifications.
This exempt remote-hybrid position is eligible for a comprehensive benefits package which includes medical, dental, vision, a 403(b) retirement account, and a generous Earned Time Off program).
** ST. CHARLES HEALTH SYSTEM
**** JOB DESCRIPTION
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* 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…