Employment Type:

Full time

Shift:

Day Shift

Description:

The purpose of the Quality & Safety Excellence Nurse is to assist and support the manager in quality and safety strategies, plans, and regulatory requirements that improve outcomes and reduce harm to patients. The individual works closely with ministry colleagues, providers, and leaders in implementing, monitoring, and evaluating quality and safety programs, structures and requirements that culminate in high reliability.  

 

The Quality & Safety Excellence nurse, under the direction of the manager, assists in achieving excellence in quality and safety work related to patient outcomes (process and outcome measures), performance improvement strategies and methodologies, culture of safety (TogetherSafe) initiatives, and patient safety organization (PSO) collaboration with risk management that ensures high quality and safe care. 

ESSENTIAL FUNCTIONS 

 

• Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) Mission, Vision, Core Values, Actions and Promise in behaviors, practices, and decisions.  

• Identifies patient quality and safety issues/concerns and collaborates with key stakeholders to address and improve. 

• Coaches for problem solving to improve quantitative and qualitative clinical outcomes and patient experience.  

• Service-aligned role to facilitate the integration of clinical quality indicators into the work environment. 

• Conducts review of medical records for data related to quality and safety initiatives required by CMS, The Joint Commission, and others as assigned. 

• Supports Nurse Governance Council as appropriate to quality and safety work.   

• Assists with TJC Survey as applicable. 

• Utilizes vendor database, or other computer program, to input, aggregate and analyze data for quality measurement directed towards improvement of organizational performance, as assigned. 

• Reports outcomes of measures to appropriate clinical leaders, medical staff, disease management groups and others as identified. 

• Educates physicians and clinical staff regarding requirements (by CMS, The Joint Commission and others) for specifications and documentation expectations for assigned quality and safety measures. 

• Works with multi-disciplinary team to ensure measure documentation is within required specifications. 

• Creates reports, scorecards and graphs necessary to communicate analysis of data. 

• Collaborates with multi-disciplinary teams to develop strategies for variance reduction and performance improvement activities. 

• Facilitates improvement work related to quality and safety that may include falls prevention, readmissions, mortality, and other projects determined by manager. 

• Demonstrates knowledge, skills and abilities to perform quality improvement activities and medical record chart abstractions to include, but not limited to: CMS core measures, Trinity Health measures, NDNQI measures, ORYX measures, medical staff measures, and selected measures related to data collection for national data bases. 

• Accurately interprets clinical information in the medical record including, but not limited to physician documentation, diagnostic tests, medications, procedures, and nursing assessments. 

• Actively participates in the quality improvement meetings as scheduled. Reports successes and deficiencies related to selected indicators.  Participates in action planning and follow-up to improve patient care and services. 

• Attends and participates in Trinity Health’s monthly Quality Contacts call, and applies information to current quality activities. 

• Participates in periodic CMS or audio conference calls, WebEx education, and other Internet communications related to CMS indicator manual revisions and other updates. 

• Participates on the Nursing Performance Improvement Committee, and other hospital committees. 

• Analyzes and interprets information to ensure requesters receive reports that are accurate, valid and reliable, and displayed in a useable and meaningful way to include usage of a variety of statistical and performance improvement tools. 

• Stroke Coordinator/Neuro Service Line QSEN as applicable per site  

• Provides medical staff support as determined by manager.  

• Other duties as assigned. 

 

MINIMUM QUALIFICATIONS 

• Bachelor’s degree in nursing, or higher preferred  

• Current RN license to practice nursing in Iowa where work is performed  
• Requires a minimum of three (3) years of experience in healthcare setting.  

• Previous hospital performance improvement experience preferred.

  

Special Skills, Competencies, and Aptitudes: 

• Must be able to use computers for documentation and other relevant activities. Demonstrates specific knowledge related to software programs such as event reporting systems, government reporting systems, and other appropriate software programs. Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools. Helpful to have experience with PowerChart/EPIC or similar tool. 

 

Our Commitment

Rooted in our Mission and Core Values, we honor the dignity of every person and recognize the unique perspectives, experiences, and talents each colleague brings. By finding common ground and embracing our differences, we grow stronger together and deliver more compassionate, person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other status protected by federal, state, or local law.