Improvement RN-St. John Medical Center

The Improvement Nurse serves as a strategic partner, responsible for facilitating on behalf of the Quality Institute, the assigned facility and/or the assigned market improvement initiatives that target one or more system priorities including the development of the scope, design, implementation, control, and validation of the initiatives outcome results. The Improvement RN may be responsible for developing and leading improvement activities at the entity and system level in the following areas:

What You Will Do

• Performance Improvement & Change Management
  * Review care of patients (concurrent and retrospective) to assess for complications of care and adherence to published practice standards
  * Liaison with the physicians, nurses and ancillary staff regarding Quality and Patient Safety, and other quality/risk initiatives, including publically reported indicators
  * Develops performance improvement activities as defined by organizational priorities
  * Attends departmental meetings, as assigned, to serve as Quality Institute representative and subject matter expert.
  * Performs tracer activity to assure compliance with all regulatory standards.
  * Serves as coach and mentor to staff regarding regulatory and other initiatives defined in Quality & Safety priorities
  * Communicates opportunities for improvement to unit/departmental leadership as identified.
  * Facilitates communication with leadership on organizational opportunities for improvement at unit or department level
  
• Patient Safety
  * Collaborates with Manager and Quality Institute Leadership in identifying annual priorities as it impacts Patient Safety
  * Supports an effective Patient Safety Program for this facility based on the current priorities
  * Participates in Performance Improvement activity related initiatives to positively impact Patient Safety and Reduction of Adverse Events
  * Assists in identifying best practices and process redesign to improve patient safety
  
• Accreditation & Regulatory Compliance
  * Assists with organization wide continuous accreditation readiness and continuous regulatory compliance, including a proactive tracer program
  * Maintains data collection to support and drive accreditation functions
  * Actively participates in process improvement initiatives to improve compliance with accreditation standards
  * Under direction of manager / administrator disseminates data and feedback on compliance with accreditation standards to all stakeholders
  * Participates with UH Accreditation team to enhance monitoring, promote needed practice changes and improve compliance system wide.
  * Is actively engaged in review of updates to accreditation standards (CMS, DNV, TJC, & Specialty) and timely communication of changes to involved stakeholders.
  * Under the direction of manager, shares regulatory (DNV/TJC/ODH/CMS) communications. Provides feedback as required to DNV/TJC via secure site.
  
• Infection Prevention Nurse
  * Perform infection surveillance, analysis, interpretation and reporting of hospital acquired infections (HAIs)
  * Act as a resource for Employee Health program working collaboratively to review and investigate potential employee Infection Control Issues and maintain compliance with federal, state and city health codes, regulations and agencies including the Ohio Department of Health, OSHA and CMS
  * Monitor and analyze patient care practices
  

  Actively participate in infection reduction initiatives in order to prevent and reduce HAIs
  * Conduct education and ongoing in-service programs for multi-disciplinary health care teams
  * Assure compliance with policy and procedure to ensure standards that meet DNV, TJC, OSHA, CMS, ODH, CDC standards, recommendations and requirements
  Maintain knowledge of current guidelines, regulations and best practices relating to infection prevention
  * In collaboration with the hospital's Infectious Disease physician, or IC Medical Director oversees and coordinates infection control policies, hospital Infection Control Committee, Infection Control Risk Assessment and Infection Control Plan, and Infection Control data submission (e.g. NHSN for CMS compliance and communicable disease reporting etc.)
  * Active membership in APIC

Additional Responsibilities

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.