Registered Nurse - Quality & Patient Safety Specialist (Full Time)

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Reporting to the Director of Quality & Patient Safety, the Quality and Patient Safety nurse specialist plays a role in reviewing publicly reported quality data by leading the measure submission process by reviewing charts in the EMR, reviewing outliers, compiling reports and serving as the liaison with clinical stakeholder and clinical committees in sharing the outcomes of the data. In addition to the goal of optimizing performance on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of safety by specifically focusing on high reliability processes to reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review clinical charts, interpret data, and implement quality improvement initiatives to deliver excellence in clinical care.

Job Description:

Principal Duties and Responsibilities

• Oversees the data collection of hospital pay-for-performance programs including but not limited to CMS Inpatient Quality Reporting, Outpatient Quality Reporting, Inpatient Psychiatry, Joint Commission and MassHealth.
• Reviews medical records to collect data for reporting quality measures, including both concurrent medical record review and periodic medical record review for audit purposes as well as medical record review for serious safety events
• Trains, coaches, and supports clinical departmental leaders and staff clinical staff in reviewing clinical charts, interpreting quality data, and implement quality improvement initiatives to deliver excellence in clinical care.
• Provides concurrent monitoring of all externally reported measures and coaching/feedback on outliers.
• Facilitate use of statistical techniques to analyze data through Medisov, Vizient, Excel, and other database software.
• Serves as the primary liaison with external measure abstractors who perform primary data abstraction on performance measures including but not limited to Q-Centrix.
• Provide expert knowledge, leadership, mentoring to patient safety initiatives utilizing safety science and principles of high reliability.
• Provide hands-on support of quality and safety work to clinicians and teams.
•  Contribute to metric development and dashboard creation and maintenance to reflect the improvement and safety work at Mount Auburn Hospital. Analyze data and prepare concise, accurate, and meaningful quality reports in accordance with quality improvement/management principles.
• Collaborate with multidisciplinary healthcare teams to rapidly identify risk, employ prevention and risk reduction strategies; assist in the monitoring of patient safety standard compliance.
•  Utilize clinical criteria and aggregates data, in the analysis of quality and patient safety issues and evaluating opportunities for improvement.
•  Conducts surveillance, chart reviews and education activities for patient safety and performance improvement; Participates in data collection, data review, analysis and event reporting.
• Remains fully informed of evolving national and local quality, patient safety, and risk management mandates and guidelines.
• Collaborates with persons clinically responsible for inpatient and outpatient departments as well as non-patient care support areas based on interpretation and evaluation of CMS, CDC, OSHA, ODH, APIC, TJC, and EPA guidelines, standards and/or regulations or other standards related to safe and effective patient care.
• Coordinates implementation of assigned projects, including plans, and keeping improvement teams on track to produce deliverables.
• Provide expert knowledge, leadership, mentoring to patient safety initiatives utilizing safety science and principles of high reliability.
• Participates in departmental education, staff meetings, and educational activities as needed.
• Participates and supports committees such as Medication Reliability, Sepsis, Perinatal committee, collaborative case review committee etc and participates in departmental M&M conferences
• Provides support in conducting Root Cause Analysis & Apparent Cause Analysis as well as clinical reviews as needed

Commitment to Care with Compassion Professional Standards

1.  Demonstrate courtesy, respect and presence: Make people feel at home when they wish they were.

• Be welcoming, approachable, and attentive; acknowledge people immediately.        
• Greet people warmly –with a smile, eye contact, and welcoming words.
• Introduce yourself and your role; wear your name badge at all times.
• Ask for and use people’s preferred name.
• Tune in. Give patients and