Facility

Cape Fear Valley Medical Center

Location

Fayetteville, North Carolina

Department

Emergency Department Administration

Job Family

Management

Work Shift

Days (United States of America)

Summary

Performance Improvement – Serves as a resource for the Emergency Department for Performance Improvement (PI). Supports the management of quality and performance improvement through participation in and coordination of activities related to use toward improvement of clinical and work processes.

Regulatory – Serves as a resource for the Emergency Department on Joint Commission and CMS standards. Assists in overseeing constant preparedness for Joint Commission, CMS, and other regulatory inspections.

Major Job Functions

The following is a summary of the major essential functions of this job.  The incumbent may perform other duties, both major and minor, that are not mentioned below.  In addition, specific functions may change from time to time:

• Serves as a resource for PI teams, PS Teams and Regulatory Teams.

• Works with PI/PS Team Leaders, Facilitators, and Teams to provide ongoing education related to process and data analysis.

• Uses flowcharts, Pareto charts, cause and effect diagrams, check sheets, scatter diagrams, and histograms as needed to interpret data.

• Collects, reviews and analyzes data while monitoring processes and identifies opportunities for improvement.

• Reviews, audits, and compiles reports utilizing the following data: EMTALA, Restraints, Sedation, Disease specific accreditation requirements, ED Quality Metrics

• Use various elements of corrective and preventive action to improve processes

• Completes background information and participates in ACA (Apparent Cause Analysis), RCA (Root Cause Analysis), and ERTs (Event Response Team) as designated.

• Assists with the tri-annual Joint Commission survey within the organization and CMS and DHHS surveys when they occur.

• Coordinates education programs on Performance Improvement, Patient Safety, and Regulatory related subjects as appropriate.

• Other duties as assigned

Minimum Qualifications

The following qualifications, or equivalents, are the minimum requirements necessary to perform the essential functions of this job:

Education and Formal Training: 

• Associates in Nursing required

• Bachelors in Nursing or completion within three years preferred

• Licensed as RN by the NC Board of Nursing or Compact State RN license required

• Background in leadership role or demonstrates strong leadership skills preferred

Work Experience: 

• 3-5 years of related clinical experience preferred

• Experience in working with Joint Commission and CMS standards preferred

• Experience with Microsoft Office to produce metrics, process flow diagrams, and strategic initiatives for presentation and education

Knowledge, Skills, and Abilities Required: 

• Knowledge of PI methodologies, Joint Commission and CMS standards, and patient safety issues

• Understanding of quality planning, cost of quality, and importance of documentation

• Experience with the audit process to include audit types as well as audit roles and responsibilities

• Experience in working with teams to include team building techniques and understanding team roles and responsibilities

• Ability to collect and review data

Physical Requirements: 

• Visual and auditory acuity required

• Able to articulate clearly and succinctly

• Much standing, walking, bending, and lifting

• May involve skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material

Required Licenses and Certifications

RN - Board Of Nursing

Cape Fear Valley Health System is an Equal Opportunity Employer M/F/Disability/Veteran/Sexual Orientation/Gender Identity