Registered Nurse - Quality and Patient Safety
Full Time
Bardstown, KY 40004
$33.60 - $48.73 an hour
Posted Today
Job description
Overview
Flaget Memorial Hospital is a 52-bed facility located in Bardstown Kentucky. We provide care for patients from Nelson Hardin Marion Washington Spencer Bullitt and LaRue counties. Founded in 1951 by the Sisters of Charity of Nazareth Flaget Memorial Hospital is nationally recognized for orthopedic care surgical care and inpatient satisfaction. We offer a complete array of services including cancer care heart care outpatient rehabilitation skilled nursing weight loss surgery pain management general surgery obstetrics and gynecology maternity care and sports medicine. The cancer center is proud to be able to provide full support and cancer care to patients through its medical and radiation oncology programs. CHI Saint Joseph Health supports 5000 active employees 8 hospitals specialty clinics and a Medical Group with more than 200 locations across Central and Eastern KY. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health in 2019. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
Responsibilities
JOB SUMMARY / PURPOSE
Reporting to the President CEO, the Manager of Quality and Patient Safety is responsible for the supervision of a facility-based comprehensive quality and safety program. The manager implements and evaluates quality, safety and experience strategies to ensure a well-planned and systematic program for the facility. The Manager implements effective programs, ensuring consistency of best practice implementation and providing oversight and ongoing performance monitoring and action planning on key standardized quality and safety metrics. The Manager leads the efforts to develop and implement standardized plans, processes, structures, strategies and tools for planning and coordinating the daily operations of the Quality department. The Manager helps ensure continual compliance with regulations and standards set for by Joint Commission and accrediting bodies. In collaboration with Clinical Leadership, the manager supports a comprehensive program to improve
The Manager identifies the need for educational programs related to quality and safety and serves as an internal consultant and subject matter expert to the facility based medical staff, administration, hospital departments and committees to carry out functions related to Quality and Safety. The Manager oversees the day to day operations of the Quality team, influencing and facilitating aspects of evidence based practice and performance improvement with interdisciplinary teams, physicians, clinical leadership and direct care staff. The Manager provides oversight of the department’s quality and patient safety staff and ensures that communication venues and committee forums are in place to ensure mechanisms for reporting and information sharing. The position facilitates the establishment of a data driven culture in the clinical quality and operational areas.
The Manager of Quality and Patient Safety provides collaborative oversight of the work product that
ESSENTIAL KEY JOB RESPONSIBILITIES
Global Quality & Patient Safety: Administrative Oversight:
Qualifications
Required Education Sys/Div/Mkt/Local Manager – Bachelor’s Degree and minimum of 3 years leadership experience OR minimum of 5 years leadership experience in the discipline OR Master’s Degree and no experience
Required Licensure and Certifications Registered Nurse, clinical licensure preferred, Nationally recognized quality-related certification preferred
Required Minimum Knowledge, Skills and Abilities Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious reporting events, safe medical practices, and Centers for Medicare and Medicaid Services (CMS) quality measures helpful
PREFERRED Qualifications Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious reporting events, safe medical practices, and Centers for Medicare and Medicaid Services (CMS) quality measures helpful Experience with Cerner, Allscripts, Meditech and other EHR software systems a plus Strong Information Technology - informatics knowledge a plus. Knowledge in Infection Control
Pay Range
$33.60 - $48.73 /hour
Flaget Memorial Hospital is a 52-bed facility located in Bardstown Kentucky. We provide care for patients from Nelson Hardin Marion Washington Spencer Bullitt and LaRue counties. Founded in 1951 by the Sisters of Charity of Nazareth Flaget Memorial Hospital is nationally recognized for orthopedic care surgical care and inpatient satisfaction. We offer a complete array of services including cancer care heart care outpatient rehabilitation skilled nursing weight loss surgery pain management general surgery obstetrics and gynecology maternity care and sports medicine. The cancer center is proud to be able to provide full support and cancer care to patients through its medical and radiation oncology programs. CHI Saint Joseph Health supports 5000 active employees 8 hospitals specialty clinics and a Medical Group with more than 200 locations across Central and Eastern KY. CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health in 2019. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
Responsibilities
JOB SUMMARY / PURPOSE
Reporting to the President CEO, the Manager of Quality and Patient Safety is responsible for the supervision of a facility-based comprehensive quality and safety program. The manager implements and evaluates quality, safety and experience strategies to ensure a well-planned and systematic program for the facility. The Manager implements effective programs, ensuring consistency of best practice implementation and providing oversight and ongoing performance monitoring and action planning on key standardized quality and safety metrics. The Manager leads the efforts to develop and implement standardized plans, processes, structures, strategies and tools for planning and coordinating the daily operations of the Quality department. The Manager helps ensure continual compliance with regulations and standards set for by Joint Commission and accrediting bodies. In collaboration with Clinical Leadership, the manager supports a comprehensive program to improve
patient outcomes and minimize patient harm through the implementation of processes and systems that
support a consistent, standardized culture of quality and safety.
The Manager identifies the need for educational programs related to quality and safety and serves as an internal consultant and subject matter expert to the facility based medical staff, administration, hospital departments and committees to carry out functions related to Quality and Safety. The Manager oversees the day to day operations of the Quality team, influencing and facilitating aspects of evidence based practice and performance improvement with interdisciplinary teams, physicians, clinical leadership and direct care staff. The Manager provides oversight of the department’s quality and patient safety staff and ensures that communication venues and committee forums are in place to ensure mechanisms for reporting and information sharing. The position facilitates the establishment of a data driven culture in the clinical quality and operational areas.
The Manager of Quality and Patient Safety provides collaborative oversight of the work product that
includes Clinical Performance Improvement, Infection Prevention, Accreditation and Regulatory
Compliance, Quality Improvement (peer review), Risk Management and Data Analytics / Abstraction /
Reporting operations.
The Manager monitors all infection control practices at Continuing Care Hospital. Work and communicate frequently with Hospital Epidemiologist on continued quality improvement needs and any IC needs. Reporting any concerns to appropriate organizations and timely reporting of mandated criteria to the appropriate agencies as outlined in the IC policies. Works closely with host facility on IC practices and updates.
The Manager submits CMS Care Data Set submissions as required by CMS to include all mandatory components. Timely submission of Care Data Sets as set forth by CMS. Stays current with CMS requirements and communicates any changes or needs to CMS requirement to leadership team.
The Manager coordinates with other operations and Medical Staff leaders the activities of the department related to Quality Performance Improvement and Clinical Patient Safety and Infection Control.
ESSENTIAL KEY JOB RESPONSIBILITIES
Global Quality & Patient Safety: Administrative Oversight:
- Provide oversight and day to day operations for assigned department(s) and administrative
functions in all areas of quality and safety
- Manage personnel and financial daily operations of the department, to include but not limited to:
interviewing, hiring, evaluation, disciplining and termination of staff; managing annual budgets to
ensure necessary staffing, equipment and supplies
- Direct the work of local quality staff to ensure full compliance with regulatory and accrediting
standards and facility goals
- Serve as a liaison to medical staff, administration and hospital departments and committees
- Collaborate local CMO, CNO, and other leaders to achieve optimum divisional & facility specific
quality, safety and experience outcomes
- Participate in the annual implementation, review and evaluation of the facility’s quality, safety &
performance improvement plan
- Maintain up-to-date departmental policies and procedures, protocols and guidelines
- Provide facility oversight of data collection, management, submission and presentation for
performance improvement (PI) and patient safety initiatives as well as managing the quality plan
- Ensure the systematic evaluation of services in accordance with the Quality / Performance
Improvement plan
- Apply current concepts in quality and safety, high reliability and standardization
- Maintain current knowledge of the Joint Commission and other relevant regulatory and reporting
standards
- Support quality standards and expectations, including ongoing monitoring and timely reporting of
meaningful results
- Partner with facility-based leaders to implement accountability processes for outcomes
- Identify the need for development, training and continuing education of staff
- Demonstrate knowledge of national initiatives such as pay for performance and quality
transparency
- Maintain knowledge of current and future trends in quality, safety, performance improvement,
accreditation and healthcare economics while being attuned to the needs of patients, team
members, physician, payers and regulatory bodies
- Support all SafetyFirst efforts and role model expectations and techniques. Implement Safetyfirst
principles towards fostering a Culture of Quality and Safety
- Promote National Patient Safety Goals either separately or concurrently with other projects
- Foster local partnerships/processes with Risk Management to perform failure mode effects
analyses in identifying high risk processes and systems to proactively promote safe care
- Foster local partnerships with Risk Management to participate in the review / investigation and
analysis of occurrence reports, causal factor data and determine action plans
- Establish local partnerships with medical staff, clinical staff and leadership of clinical / non-clinical areas to improve core measures and quality indicators performance.
- Judgments and Initiatives include process interpretation for peer review. Comprehensive knowledge of departmental functions and QM staff responsibilities. Must offer improvement suggestions with QM department processes (i.e., planning). Must demonstrate ability to communicate with multi-disciplinary teams.
Qualifications
Required Education Sys/Div/Mkt/Local Manager – Bachelor’s Degree and minimum of 3 years leadership experience OR minimum of 5 years leadership experience in the discipline OR Master’s Degree and no experience
Required Licensure and Certifications Registered Nurse, clinical licensure preferred, Nationally recognized quality-related certification preferred
Required Minimum Knowledge, Skills and Abilities Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious reporting events, safe medical practices, and Centers for Medicare and Medicaid Services (CMS) quality measures helpful
PREFERRED Qualifications Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious reporting events, safe medical practices, and Centers for Medicare and Medicaid Services (CMS) quality measures helpful Experience with Cerner, Allscripts, Meditech and other EHR software systems a plus Strong Information Technology - informatics knowledge a plus. Knowledge in Infection Control
Pay Range
$33.60 - $48.73 /hour
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