The Clinical Quality RN supports the achievement of the quality and patient safety priorities through quality assurance, quality management and quality improvement projects. This position facilitates data collection, analysis, reporting, presentation and corrective action determinations. This position also facilitates the medical staff peer review and compliance with regulatory requirements related to organizational performance improvement.
ESSENTIAL FUNCTIONS OF THE ROLE
Assists staff and management in the determination of reliable, valid and measurable quality and patient safety indicators.
Identifies regulatory obligations for quality assurance (QA) and quality control (QC) activities, and assures that the organization is addressing regulatory requirements related to quality and patient safety.
Serves as the liaison between quality and patient safety activities and the associated data sources to assure the best data collected in the simplest, most efficient manner.
Supports the medical staff elements of the QA activities; processes medical management issues identified through the Medical Staff Peer Review Program. Identifies opportunities for quality improvement (QI), QA, or QC activities; initiates appropriate problem definition, process analysis, data collection and analysis, reporting, and remeasurement.
Identifies processes that are in statistical control and those that are not; special cause vs. common cause variation. Implements appropriate actions based on this analysis.
Uses key tools to focus on process review rather than people review including process flow charting, priority matrices, Failure Mode and Effects Analysis (FMEA), run charts, Statistical Process Control (SPC) charts, and affinity diagrams.
Works with medical and clinical leadership to organize, design, and present reports on quality and patient safety initiatives.
Participates in the annual evaluations of program and provides Annual Report to primary QPSC regarding patient safety and quality management.
Participates in, as needed, the Medical Staff Peer Review Program, supporting data collection, analysis and aggregation at appointment and reappointment cycles.
Collaborates with Risk Management to assure information used in analysis and process or performance improvement enjoys the privacy and confidentiality protection afforded by law.
KEY SUCCESS FACTORS
Must possess project management knowledge and application of quality tools and methods.
Must have a working knowledge of key quality and regulatory organizations, such as the Joint Commission on Accreditation of Heathcare Organizations (JCAHO), the Institute for Healthcare Improvement (IHI), the National Association for Healthcare Quality (NAHQ), and the National Committee for Quality Assurance (NCQA).
Ability to maintainstrict confidentiality of information acquired in the course of duties.
Expert knowledge in the QI initiative assigned including purpose of initiative, key elements, indicators, reporting, problem resolution and communicating results.
Effectively communicates activities and shared learning's vertically and horizontally within the facility and the system. Requires strong speaking and communication skills.
Current Certified Professional in Healthcare Quality (CPHQ) certification preferred.
Facility: Baylor Scott and White Hospital- College Station, TX
Shift/Status: Full Time, Days
Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!