Job Description

Quality Improvement Nurse

Under general supervision, coordinates Shock Trauma performance and quality improvement activities to ensure consistency with organization policies, procedures and philosophy, and to maintain and improve the quality of care given to the patient and families. Develops, implements and documents activities relating to the Quality Performance Improvement Program. Collects, and analyzes data, conducts presentations, provides consultation, and participates in hospital-wide and Shock Trauma Quality related committees to ensure collaborative effort across disciplines. Ensures a constant state of readiness for the Shock Trauma Center PARC designation.

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Works with the Trauma Program Manager (TPM) to concurrently manage data from the Shock Trauma Registry and support the Shock Trauma Quality Program.

A. Provides education and support to the Shock Trauma Registrars

B. Inter Rator Reliability (validation of trauma registrar work)

C. Concurrent review of primary trauma patient charts per PARC standards

D. Performs Injury review with Trauma Registry Clinical Data Specialist

E. Participates in monthly meetings (TQIC, TRU committee, QIC)

F. ACS Filter Review

2. Collaborates with the TPM to plan, organize, and direct Shock Trauma Performance Improvement activities. Participate in studies of identified problem areas in accordance with the Performance Improvement Plan.

A. Meets regularly with the Physician Director for Quality Management, Trauma Program Manager & Quality Program Administrator in order to review Shock Trauma Patient complications and deaths; review data to be presented at departmental quality management meetings; and present quality issues related to ACS filters, complications from the STC registry, and inter-hospital transfers.

B. Reviews data related to clinical care, in conjunction with the quality management committee, to assist in determining committee agenda and identify areas requiring further information.

Collaborates with Trauma Program Manager & Quality Program Administrator to prepare statistical reports as required for medical staff, quality management committees and quality task forces to identify trends or patterns that present an opportunity to improve the quality of patient care provided at STC.

D.

Shares trends, patterns or issues identified during concurrent reviews, providing explanation and details regarding monthly quality assurance reports, and/or obtains medical records or additional information to be discussed.

E.

Facilitates the clinical review and problem-solving processes through the use of quality improvement methodology and tools.

F.

Participates in MIEMSS quality related committees to obtain comparative data on quality indicators, to use in assessing how well the institution is doing in relation to others and compliance with standards.

3. Analyzes and assesses the important aspects of care for trauma patient populations which represent important clinical issues and reflect the strategic clinical direction of the organization. Identifies areas for improvement.

A. Works with the healthcare team & the Trauma Program Manager to determine the quality of care provided to support compliance with The Joint Commission & PARC (COMAR) standard of multidisciplinary approach to quality improvement.

B. Identifies opportunities for improvement in the care provided.

4. Collaborates with the TPM to develops strategies and action plans to correct the improvement areas. Responsible for ensuring that the goals are met based off of the action plans and ensures documented loop closure.

5. Collects quality and risk management data on an ongoing basis.

A. Collaborates with the STC Registry to assess data using pre-determined, medical staff approved criteria to identify cases requiring peer review, identify causes for indicator rate outliers and to document trends or patterns that identify opportunities for improvement in the quality of care provided.

B. Provides feedback to the TPM regarding patient outcomes and processes of care.

6. Participates in organization-wide quality improvement committees and participates on process management teams.

Education and Experience

1. Bachelor's degree in Nursing or an Allied Health field, or an equivalent combination of education and experience, is required.

2. Current licensure as a Registered Nurse or Allied Health Professional in the State of Maryland is required.

3. Five years of experience as an RN of an Allied health Field required. One to three years of trauma related care are required.

4. Three years of professional experience performing utilization review/quality management activities, concurrent medical chart review, data management or equivalent, is preferred.

Knowledge, Skills and Abilities

1. Knowledge of state and federal regulations, and The Joint Commission standards and practices for acute care hospitals is required. Knowledge of Departmental of Health and Mental Hygiene (DHMH) for state licensure and Medical conditions of participation. Knowledge of quality improvement and risk management is required. Familiarity with physician practice standards, and legal and ethical practices

2. Knowledge of Shock Trauma PARC Designation requirements and process.

3. Knowledge of the ICD-10 coding process.

4. Highly effective verbal and written communication skills are necessary to work with medical, nursing staff and external review agencies in monitoring and evaluating the quality of patient care.

5. Ability to learn facilitation of clinical quality improvement and the problem-solving process in a clinical setting. Ability to learn quality improvement tools and methodology.

6. Ability to assess utilization and quality management problems, recommend solutions, and resolve issues in a timely, efficient and effective manner.

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