Accountable for the comprehensive administration of key functions, roles, systems and processes in assigned areas of responsibility including quality and patient safety monitoring, organizational accreditation and regulatory compliance. Develops, operationalizes, and leads special projects as directed by the CEO and CMO/VPMA which enhances the mission, vision, and beliefs of the organization. These projects will be identified and assigned as appropriate for the organization and may require the coordination of multiple staff, providers, resources both internal and external to the organization. Serves as a resource/liaison to provide interpretation, expertise and advice regarding maintenance of standards required by the approved accreditary or regulatory agencies to Administration, managers, department directors and Medical Center staff. Serves in a capacity to promote a culture of continuous quality improvement, patient safety, and risk mitigation. Provides and analyzes data to support a culture of excellence and change as required by this position.
PRINCIPAL JOB FUNCTIONS:
*Commits to the mission, vision, beliefs and consistently demonstrates our core values.
*Functions as Director for areas of responsibility ensuring alignment with the provision of patient care.
*Activates resources and integrates nursing services with other departments to foster patient-centered care.
*Assures consistency in interpretation and application of the care delivery model, mission, vision and beliefs of the organization.
*Develops capital and operating budgets with input from managers, coordinators and officers for areas of responsibility in accordance with budget timetables.
*Works with managers, coordinators, officers and staff to assure expenses are within budget parameters for areas of responsibility; reviews and analyzes budget and other management reports and takes action as needed to assure effective and efficient operations.
*Develops and sustains standards of care and practices which are consistent with current trends for existing programs/services.
*Coordinates and collaborates with the organization on the journey of continuous quality improvement and safety with aspirations of achieving zero harm.
*Develops, directs, leads, and operationalizes special projects as assigned by the CEO and CMO/VPMA which enhances the mission, vision, and beliefs of the organization.
*Directs and leads the requirement for the Electronic Health Record order set compliance accreditation standards.
*Develops programs and services based on needs analysis and facilitates their implementation and evaluation.
*Keeps abreast of current clinical trends and technology for areas of responsibility and provides a system perspective for managers and staff.
*Implements the Medical Center Corporate Compliance Plan; assists with review of the facility's plan for Patient Care *Services and recommends adjustments.
*Hires, trains, supervises, disciplines and evaluates the performance of assigned personnel; establishes and maintains job descriptions for areas of responsibility.
*Meets or exceeds Joint Commission or other organizational approved regulatory and accreditation standards.
*Resolves clinical concerns through working with Hospital and Medical Staff Leadership.
*Provides leadership and participates in Medical Center improvement initiatives and teams as assigned.
*Collaborates with the CMO/VPMA in the establishment of priorities for implementation of processes and tools necessary to support change and a culture of continuous improvement meeting and complying with accreditation and regulatory standards.
*Collaborates with Administration, external consultants and other leaders to plan, develop and implement required changes to continuously improve patient/physician perceptions through the application of service and operational principles.
. Screens and evaluates proven patient/physician/employee practices for potential use at facility to enhance continuous improvement of services.
*Serves as internal consultant to senior management, medical staff and hospital departments in all matters related to regulatory agency standards and compliance.
*Maintains current knowledge of regulatory and accrediting agencies requirements and ensures that requirements are addressed on an ongoing basis.
*Provides oversight for the required clinical data retrieval, analysis and submission to external agencies to support quality improvement initiatives and compliance with regulations and standards.
*Oversees the process required for the preparation and dissemination of policies and procedures of the organization in collaboration with Medical Center leaders.
*Serves on assigned hospital committees and attends other meetings as requested or required.
*Formulates and administers department procedures.
*Performs other related projects and duties as assigned.
REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:
1. Knowledge of facility’s mission, history, policies and tradition.
2. Knowledge of quality philosophy, principles, team building, changing cultures, change theory and quality tools.
3. Knowledge of computer hardware equipment and software applications relevant to work functions.
4. Knowledge of accreditation standards and compliance practices, budgetary and financial methods and practices.
5. Knowledge of nursing and hospital systems, nursing trends and applied nursing processes.
6. Knowledge of publicly reported clinical quality and patient safety measures.
7. Knowledge of clinical and patient care-related processes.
8. Knowledge of medical and pharmacological terminology.
9. Knowledge of the principles and theories of process improvement, business management, statistical analysis, budgetary and financial methods and practices.
10. Knowledge of current process improvement methodologies and their application to healthcare.
11. Ability to communicate effectively both verbally and in writing.
12. Ability to work in a fast-paced environment related to changing patient needs.
13. Ability to maintain confidentiality relevant to sensitive information.
14. Ability to establish and maintain effective working relationships with all levels of personnel, medical staff, volunteer and ancillary departments including diverse patient populations.
15. Ability to develop written policies and procedures, memoranda and performance evaluations with measurable behaviors.
16. Ability to lead multi-disciplinary teams and work as a team member.
17. Ability to balance and prioritize diverse management and clinical responsibilities.
18. Ability to schedule, direct, counsel and evaluate employee work and performance.
19. Ability to maintain regular and punctual attendance.
EDUCATION AND EXPERIENCE:
- Current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act required.
- Masters degree in Nursing, Health Care Administration or related field required.
- Minimum of three (3) years progressive experience in a clinical position required.
- Minimum of five (5) years progressive responsibility in a healthcare environment developing and implementing improvement of regulatory compliance programs as required.
- Minimum of three (3) years experience in management or supervisory role required.