As one of the nation’s leading pediatric health care systems, Nemours is committed to providing all children with their best chance to grow up healthy. We offer integrated, family-centered care to more than 300,000 children each year in our pediatric hospitals, specialty clinics and primary care practices in Delaware, Florida, Maryland, New Jersey and Pennsylvania. Nemours strives to ensure a healthier tomorrow for all children – even those who may never enter our doors – through our world-changing research, education and advocacy efforts. At Nemours, our Associates help us deliver on the promise we make to every family we have the privilege of serving: to treat their child as if they were our own.
Facilitates commitment to an organization-wide quality/safety culture and strategy. Coordinates and participates in the collection of data from medical records, logs, databases and error reporting systems that support performance improvement and patient safety activities of the Hospital and the Practice. Coordinates the collection of quality/safety related data for peer review and the medical staff reappointment process. Coordinates and facilitates the Failure Mode, Effects Analysis and Root Cause Analysis processes.
This position is responsible for organizing, compiling, documenting, and analyzing data to produce reports from which opportunities for quality/safety improvement, intervention and educational activities can be identified. Educates staff in continuous quality improvement and patient safety concepts, processes, and tools. As necessary, researches and provides education on state, federal and other regulatory agencies’ standards. Utilizes the quality methodology in training departments and multi-disciplinary teams. Works with Hospital and Medical staff at all levels of the organization to design and implement data collection methodologies, databases, action plans, and reporting strategies. Facilitates teams as necessary to achieve performance improvement within the organization.
Participates as a member of Hospital and Medical Staff Committees, as assigned. Cross covers, as needed, to meet the responsibilities of the department as a whole. This position supports these activities in the inpatient or ambulatory/ physician practice environment as assigned.
Facilitates the participation of individual department, service or Medical Staff in organization-wide quality/safety activities.
Collaborates with Hospital, Practice and Medical Staff leadership and key committees to develop long-range goals, objectives, and strategies for quality/safety improvement.
Assists in the identification of specific organizational needs and priorities related to quality improvement and patient safety utilizing a variety of sources including, but not limited to, measurement data, variance reports, patient/staff suggestions, team recommendations, comparative data, regulatory standards/reports, focus groups and knowledge-based information.
Establishes a process, in collaboration with Departmental Leaders, for proactively assessing the Hospital and/or Practice for quality and safety improvement opportunities.
Utilizes Tracer Methodology to assess compliance with Accreditation Standards
Designs data collection processes and tools as appropriate to the project.
Supports the Medical Staff and departmental leaders in the management of processes and data to meet regulatory, accreditation and peer review requirements.
Conducts concurrent and retrospective focused studies to evaluate and analyze targeted areas of performance.
Analyzes data to identify trends and opportunities for improvement as assigned.
Prepares data into meaningful information using forms, reports, graphs, tables, slides, and other documents to communicate results. Presents, as appropriate, data results to administration, medical staff, departments, and committees.
Facilitates multidisciplinary teams or committees as assigned.
Assists managers and employees in identifying action plans to improve performance and safety in the Hospital.
Facilitates and/or prepares formal documents, reports, plans or policies to support quality and safety activities, i.e. Root Cause Analysis, Intensive Process Review & Analysis, Failure Mode Effects Analysis, Team Proposal forms, progress reports, data definitions, etc.
Designs and assures the capture of quality/safety data for the Medical Staff reappointment process by working with the Medical Staff to identify, define, and determine the best method for collecting quality-related reappointment data.
Supports the Medical Staff peer review process through indicator screening, case identification and referral.
Facilitates and participates in the evaluation of quality/safety program effectiveness.
Educates and acts as a resource to all hospital and practice personnel on quality methodologies and regulatory standards related to quality and patient safety. Participates in HR-sponsored New Associate Orientation through presentation of PI and Patient Safety topics.
Functions as a preceptor for PI/PS Coordinators and Data Analysts
Keeps Director of Quality and Patient Safety appraised of barriers to completion of objectives
Functions in place of and provides departmental coverage on behalf of the Director of Quality and Safety in the absence of the Director. This includes but is not limited to participating in unannounced regulatory/accreditation survey visits and other interactions with Hospital and Medical Staff Leadership.
Participates in various organizational and medical staff committees as assigned.
Collaborates on Quality and Patient Safety initiatives with other Nemours entities including, but not limited to, Nemours AI DuPont in the Delaware Valley.
All other duties as assigned.
Strong verbal and written communication skills.
Demonstrated Presentation Skills
Demonstrated Project Management and Facilitation Skills
Ability to handle several projects simultaneously.
Quantitative analytical skills essential.
Ability to work independently and within a team environment
Demonstrated skills with Microsoft Office applications and other databases
Organized with attention to detail
Ability to effectively provide coaching and feedback to teams at all levels.
Ability to view opportunities for improvement through a systems perspective
Must be a licensed Registered Nurse in the State of Florida.
Certification in Healthcare Quality, Lean, or Six Sigma preferred
Demonstrated experience and achievement in Performance Improvement and Quality Assurance, preferably in a healthcare provider setting.
Experience in dealing with regulatory agencies
Experience in utilizing and teaching a variety of quality methodologies/models
Experience in the use of manipulation of databases
Job Related Experience and On-The-Job Training
More than 10 years experience in health care performance/quality improvement and patient safety.
Our dedication to professionals who are dedicated to children frequently earns Nemours a spot on the list of top workplaces in the communities we serve. Our Associates enjoy comprehensive benefits, including our unique “Bridge to a Healthy Future” pediatric health plan, an integrated wellness program, opportunities for professional growth, and much more. As an equal opportunity employer, Nemours focuses on the best-qualified applicants for our openings.
Internal Number: 30168
Nemours is committed to improving the health of children. As a non-profit children’s health organization, we consider the health of every child to be a sacred trust. Through family-centered care in our children’s hospitals and clinics in Delaware, New Jersey, Pennsylvania and Florida, as well as world-changing research, education and advocacy, Nemours fulfills the promise of a healthier tomorrow for all children — even those who may never enter our doors. Nemours began more than 70 years ago with the vision of Alfred I. duPont to improve the lives of children and to do whatever it takes to prevent and treat even the most disabling childhood conditions. Today, through our children’s hospitals and health system, we directly care for 250,000 children annually in Delaware Valley and Florida, including families who travel from across the country and world to see our specialists — treating every child as we would our own. We also reach beyond the walls of our hospitals and clinics to be a voice for children on a national and international level, and to lead the way in prevention, intervention, education, and research. Nemours is growing to better serve the children and families in our ca...re. We have 1.1 million square feet of space currently devoted to providing children’s healthcare or under construction, all designed with significant input and advice from our patients and families.