Description

POSITION EDUCATION/ QUALIFICATIONS­:

• Texas Registered Nurse (R.N.) license required
• Graduate from an accredited Nurse Program
• Current BLS Certification, ACLS preferred
• Requires a proficiency level typically attained with three (3) years clinical nursing experience.
• Must have good communication skills. 
• Must have strong organization skills and be able to work independently.
• Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians
• Ability to read, write and speak English

JOB KNOWLEDGE/EXPERIENCE­:

• Promotes the facility mission, vision and values by effectively communicating them to others. Considers mission, vision and values in developing services, standards and practices
• Must maintain current knowledge of Texas law and CMS regulations.
• Facilitates coordination of sepsis compliance activities that includes policy and procedure development, survey preparation, survey management and follow up, assessment of standards sepsis compliance and reporting of vulnerabilities to key stakeholders.
• Requires experience in performance improvement methodologies; quality measurement; and data analysis using statistical principles.
• Working knowledge of quality improvement principles and methodologies utilized in health care.
• Knowledge of the Joint Commission and CMS, its processes’ and standards.
• Commitment to the basic philosophy generally described in Total Quality Management (TQM) and ability to embody this philosophy in the work place.
• An affirming style of leadership in working with others.
• Knowledge of adult education theory and practice and the ability to plan organize and lead educational sessions.
• Designs compliance studies, develops criteria for evaluation, and assists assigned hospital departments with appropriate data collection and data analysis.                                                  
• Reviews and interprets patient care information, discharge summaries, operation reports, and other data sources used to assess quality care issues.
• Creates reporting documents for departments to use for tracking compliance activities, trends and patterns, and identifying opportunities for improvement.
• Provides education on data analysis and utilization of information to clinical compliance and Joint Commission teams.
• Attends and may facilitate department compliance meetings, infection control meeting by providing input regarding problem identification and resolution, continuous quality improvement (CQI), and other patient care and accreditation activities.                                                                                                                   
• May provide ongoing clinical support to Hospital programs by reviewing and logging charts and incident reports, and recording improvement activities and results.
• Assists with developing and maintaining effective, comprehensive continuous compliance programs.
• As requested, prepares reports for, and recommends research topics to, the Quality Improvement Committee.
• Develops record keeping and reporting functions and maintains appropriate
• Develops effective data collection and evaluation tools to identify opportunities to improve patient care.
• Assists with the establishment of tools to collect and organize data used in monitoring and continually assess the success of problem resolution activities.
• Maintains Compliance Data, as required.
• Completes and maintains records for problem status for follow-up.
• Maintains and distributes corrective action reminder report to responsible persons.
• Plans meetings and disseminates information to appropriate areas, as directed.
• Good listening, writing and oral communication skills.
• Ability to assess and to explain data from broad perspective.
• Demonstrates the ability to manage multiple tasks and projects in a productive manner
• Demonstrates interdepartmental support and teamwork through a supportive and collaborative approach
• Organizes, schedules and conducts internal audit process to measure survey readiness (mock surveys, tracer activities, etc.)
• Tracks and trends regulatory compliance issues
• Prepares quarterly leadership report regarding regulatory compliance
• Assures measurement of all required PPR elements
• Coordinates PPR completion and submission
• Coordinates QRS Survey
• Coordinates all on site regulatory, licensure and accreditation surveys
• Knowledge of PC technologies, including operating and application software
• Educates hospital staff, medical staff and leadership regarding regulatory requirements/changes
• Other duties as assigned

POSITION RESPONSIBILITES:

• Provide support functions for all aspects of the sepsis program
• Collaborate with nursing management and staff nurses to define, guide, and evaluate nursing practice in the provision of sepsis care; including creation of policies and procedures related to sepsis care
• Serve as a nursing consultant to members of the community, EMS, and other hospitals
• Assume responsibility of accruing and evaluating new knowledge and skills in the area of sepsis care
• Acts as a resource and liaison for patients and families
• Assess and evaluates all aspects of care rendered to the septic patient
• Analyzes registry and regulatory data on septic patients to identify trends for strategic planning and performance improvement
• Coordinates sepsis course according to guidelines according to The Joint Commission and other regulatory bodies / current evidence-based practice
• Evaluates and implements appropriate research findings in nursing practice
• Assists with any appropriate in-house sepsis research studies, as applicable
• Serves as a liaison to administration, representing the sepsis program on various hospital and community committees to enhance and foster a fiscally sound and quality/outcomes-driven sepsis program
• Participates in professional educational programs and conferences
• Performs other duties as assigned

LINES OF REPSONSIBILITES:

(Chain-of-command)

            Chief Quality Officer…Director of Quality…RN Quality Supervisor