Wentworth-Douglass Hospital, a subsidiary of Massachusetts General Hospital, is renowned as one of the largest acute care hospitals in the Seacoast region of New Hampshire and Southern Maine. At Wentworth-Douglass, we value people who contribute to patient-centered care that enhances community health; we recognize and reward those who share our values and transform our patients' lives. We invite you to explore opportunities, cultivate community wellness and professional growth.
1. Core Measures/eCQMs
a. Manages and monitors core measure care processes, to include daily medial record review and compliance documentation via Midas for QIO and Joint Commission.
b. Applies core measure criteria to assess and document the appropriateness of care as outlined by the standards. Collaborates with the healthcare team to ensure criteria are met.
c. Collects and analyzes Core Measure, and other regulatory or certification. reports/data. Collaborates with healthcare teams (and departments) to facilitate improvement of care.
d. Assists with development and promotion of core measure educational material.
e. Educates and mentors departments regarding core measures and their impact on patient health.
f. Leads cross-functional teams to facilitate the improvement of care processes and incorporate best practices.
g. Review core measurement admissions daily and assure best clinical practice guidelines are being used, in conjunction with Physician and Nursing care (or work with staff to document the reason(s) for exclusion).
h. Coordinate and Facilitate Reliability Core Measurement Meetings, share findings with appropriate staff and department chairs.
i. Coordinate efforts with and assist diagnostic coding personnel with questions/issues of coding for diagnoses for which Core Measures, and other regulatory or certification measures, are in effect.
j. Educates staff on quality measures, benchmarks and results on a regular basis.
k. Validation of eCQMs.
2. Leads or participates in projects
. Successfully completes project management course/Green Belt.
a. Actively participates in assigned projects.
b. Leads projects with team members as requested.
c. Successfully monitors and reports project data.
d. Evaluates the success of assigned projects.
e. Utilizes appropriate tools throughout data collection phase of projects.
f. Completes at least one project per year.
3. Facilitates RCA's
. Directs RCA process to include analysis of event, pertinent findings and action development.
a. Prepare and present the preliminary report for the Sentinel Event Task Force to determine if it's a reportable event.
b. Guides RCA team through the identification of the root cause of the event.
c. Participates in action item updates with the RCA team.
d. Prepare and present the final RCA report and action plan to the Sentinel Event Task Force.
e. Prepare the letter and documentation required by the NHDHHS and submit within required reporting time frame.
f. Conducts mini RCA's on units or with appropriate participants for select non-reportable adverse events.
g. Participates on RCA team to oversee/ensure sustainability of action items.
4. Patient Safety
. Fosters an environment of professional accountability, just culture and safety.
a. Works collaboratively with Clinical Quality/Safety nurses to identify opportunities for patient/staff safety initiatives.
b. Participates in CUSP or other clinical safety initiatives for specific unit safety rounding.
c. Utilizes safety rounding information/findings as an opportunity to work collaboratively with assigned areas to bring identified items to closure.
d. Facilitates team building and quality monitoring.
e. Provides safety data to clinical areas on a regular basis.
f. Works collaboratively with unit educators, Clinical Nurse Leaders, Clinical Practice nurses or other pertinent staff to enhance patient safety and achieve quality improvement.
g. Facilitates the provision of clinically competent care by staff/team through education, role modeling, team building and quality monitoring.
Experience Minimum Required
• Ability to work with minimal supervision while exercising effective decision-making initiative, diplomacy, tact, delegation, and organizational skills.
• Care review using RN clinical skills.
• 3 Nursing Years of Experience.
• Experience Preferred/Desired
• Quality Improvement Experience
Education Minimum Required
• RN with a Bachelors Degree
• Education Preferred/Desired
• Masters Degree in Nursing or Health related field.
Training Minimum Required
• Quality Certification within 24 months of hire.
• Patient Safety Certification within 24 months of hire.
• Green Belt within 24 months of hire.
• Training Preferred/Desired
• Certification in Patient Safety (CPPS)
Special Skills Minimum Required
• Ability to use PI tools to facilitate teams to ensure continuous improvements with core measures and other PI projects.
• Ability to interact well orally and through written correspondence with all aspects of the organization.
• Project Management completed within first year.
• Special Skills Preferred/Desired
• Excel, Powerpoint
Licensure and/or Certifications Required
• Registered Nurse License
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