Rn External Quality Improvement

Experience and education: Critical care or emergency room experience is desired. Knowledge of best-practice care of the sepsis patient population is highly preferred. Excellent organizational skills and attention to detail. This position supports the Centers for Medicare & Medicaid Services (CMS) Severe Sepsis/Septic Shock Measure.

Job-specific:

• Position located at Beaumont Service Center and assigned to Beaumont Hospital- travel required

• Ability to travel to all hospital sites as needed

• EPIC Chart abstraction for quality measurement related to pay for performance

• Data outcomes analysis, reporting, and presentation to hospital quality improvement teams to drive improved patient outcomes

• Ability to conduct presentations in front of large audiences

• Knowledge of Formal PI methodology

• Knowledge of Kaizen and Kaizen training activities

• Ability to independently work within Word, Excel, and PowerPoint.

GENERAL SUMMARY:

The External Quality Improvement Nurse utilizes clinical and data analytical expertise to identify quality and patient safety trends, promotes patient safety throughout the continuum of care and leads teams to improve quality and patient safety. This is a system level position, which supports quality and safety work across all local sites. Requires interaction with multiple levels of organizational staff, from front line care providers to senior executive leadership. Is directly involved in local site / system committees and process initiatives to assist leadership with creating process improvements designed to optimize care, quality, and patient safety related performance improvement activities. Will develop a relationship with physician champions to move forward initiatives, meeting deadlines and standards with minimal supervision, and report findings and trends to registry / collaborative according to established standards and deadlines.

ESSENTIAL DUTIES:

1. Responsible for timely clinical data abstraction for assigned registry / collaborative while following standards and deadlines.

2. Part of a system level team but acting as an extension of the local quality site team to help improve quality and patient safety measures.

3. Attend registry / collaborative meetings as the representative for the health system.

4. Coordinate data collection, data analysis, trending and reporting to enhance patient care and safety improvements. Utilize data to drive best practice for quality and safety improvements within and across care delivery settings.

5. Responsible for analyzing and processing appropriate reports to provide the necessary data to meet pay-for-performance and payer requirements.

6. Ensure compliance with registry / collaborative specifications and other reporting body criteria, including participating in regular audits and reviewing updated specifications.

7. Investigate, facilitate, and track the root cause analysis work, including the root cause development and action plan implementation monitoring from end to end.

8. In conjunction with the system leadership team, site quality director and physician champion, organizes and conducts regular check ins on improvement plans for clinical care areas to: embed a culture of safety, identify safety improvement opportunities, and establish support for safe clinical practice.

9. Assist department/physician leadership with standards and report interpretation and recognition of trends and PI opportunities

10. Work independently to provide clinical and performance improvement subject matter expertise to departments, medical staff, and clinical operations to successfully achieve specific quality and patient safety targets.

11. Initiate and participate in interdisciplinary projects to improve organizational performance related to quality and patient safety.

This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described.

STANDARD REQUIREMENTS:

1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process.

2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others.

3. Supports and adheres to all Beaumont Health’s customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform, and dress code.

4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee, and operations information.

5. Supports and participates in a collaborative team-oriented environment – cooperates and works together with all co-workers, plans, and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns.

6. Supports, cooperates with, and demonstrates safe work practices and attitudes, follows safety rules – including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs.

7. Completes all required compliance standards that may be department specific and/or identified by the organization.

8. Maintains current licensure, registration and/or certification, as applicable, always.

STANDARD QUALIFICATIONS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

A. Education / Training and Work Experience

• Associate’s degree in nursing required

B. Work Experience

• For Bachelor’s degree candidates: 3 – 5 years’ experience in clinical data abstraction, patient safety activities, and/or clinical quality improvements required

• For Associate nursing degree applicants: 5 – 7 years’ experience in clinical data abstraction, patient safety activities and/or clinical quality improvements required

C. Certification, Licensure, Registration:

• RN licensure required

• Certification in patient safety/process improvement preferred.

D. Other Qualifications:

• Advance skills in Microsoft suite, including PowerPoint, Excel, and Word

• Experience with Epic (or EMR)

• Ability to present data to various groups

• Experience with process improvement methodology, preferred

• Has ability to know when to seek assistance with tasks and projects

• May provide training and mentorship to other team members

• Minimal input from manager regarding work product

• Self-directed when assigned a new project

• Able to identify and take the lead on tasks and/or projects

WORKING CONDITIONS:

A. Physical Effort:

• Strength

Position requires ability to frequently push/pull up to 30 lb. objects with assist of others, occasional requires ability to lift objects more than 50 lbs. with others, constantly lift objects up to 20 lbs. And frequently lift to 40 lbs.

• Manual Dexterity

Position requires incumbent to constantly perform simple motor skills such as standing, walking and simple manipulative skills such as writing.

• Coordination

Position requires incumbent to constantly perform gross body coordination such as walking.

• Mobility

Positions requires incumbent to constantly walk and stand; occasionally sit for prolonged periods.

• Visual Discrimination

Positions requires incumbent to constantly see objects far away as in driving and see close objects such as reading thermometers.

• Hearing

Positions requires incumbent to constantly be able to hear normal sound with some background noise as in answering phone/intercom.

B. Work Environment:

• Employee may be frequently exposed to electro-magnetic radiations as in VDTs. Occasionally exposed to hazardous material other than blood, body tissues, or fluids, dust, toxins, cytotoxins, chemical hazardous materials, bodily

injuries, loud and/or unpleasant noises, high humidity, electrical hazards, or poisonous substances. Infrequently exposed to blood, body tissue, or fluids. Seldom exposed to fluctuations in temperature, grease, oil, and radiation.

• Expected to travel between sites for this position.

Beaumont offers a comprehensive benefits package to meet your financial, health and life-work balance goals.

• Exceptional health, dental, vision and prescription drug insurance plans
• Generous paid time off, holidays and flexible scheduling
• NEW On-demand pay program – powered by Payactiv
• Relocation assistance
• Generous retirement savings, disability insurance, identify theft protection and even home and auto insurance
• Our employees receive special discounts on a wide range of products and services

Our diverse and talented teams of professionals and clinicians don’t just share in the success of our system; they make it possible. Driven by our shared commitment to making our communities healthier and stronger, we are leading the way in health care innovation with relentless ambition and a belief that anything is possible when we work together.

This is where extraordinary begins. Find out where it can take you and your career. Apply Now!

Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.

• Beaumont Health grants equal employment opportunity to all qualified persons without regard to race, color, national origin, sex, disability, age, religion, genetic information, marital status, height, weight, gender, pregnancy, sexual orientation, gender identity or expression, veteran status, or any other legally protected category.