GENERAL SUMMARY:

Responsible for facilitating patient safety monitoring, reporting and improvement activities. Facilitates assigned teams that are consistent with the organization’s Strategic Plan, Quality and Patient Safety Plan, and designated operational and clinical priorities for care.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Manages the daily review and processing of patient safety incident reports.

3. *Coordinates with department and entity leaders to ensure a thorough review of incidents.

4. *Facilitates a thorough and credible root cause analysis, including developing a corrective action plan for sentinel events.

5. *Prepares a complete root cause analysis report for communication to Senior Management and other quality and peer-review committees within specified timeframes.

6. *Facilitates the development of Common Cause Analyses and Quality Improvement Team corrective action plan(s).

7. *Monitors effectiveness of improvement activities in response to incident investigations through leadership engagement, specified metrics, implementation status tracking, and project outcomes.

8. *Assesses the impact of patient safety initiatives by supporting activities that meet the respective project aims, communicating with key hospital leaders regarding proposed changes, determining measures that assess the level

of improvement, maintaining written records of improvement activities, and using external comparisons and benchmarks to establish organizational standards for improvement.

9. *Facilitates a thorough proactive risk assessment, including developing an improvement plan.

10. *Facilitates teams/groups with the process of quality improvement by encouraging participation, suggesting methods, and coordinating meeting details.

11. Demonstrates awareness of required accreditation measures, assists staff development, and prepares the organization for accreditation.

12. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

13. Participates in meetings, committees and department projects as assigned.

14. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk “*”).

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of disease processes to include basic anatomy and physiology.

2. Knowledge of medical and pharmacological terminology.

3. Knowledge of quality improvement principles and methods, change theory, and systems thinking.

4. Knowledge of computer hardware equipment and software applications relevant to work functions.

5. Knowledge of hospital systems including the design and function of hospital medical records.

6. Ability to communicate effectively both verbally and in writing.

7. Ability to analyze problems, identify needs and priorities and implement effective work strategies.

8. Ability to facilitate multi-disciplinary teams and work as a team member.

9. Ability to establish and maintain effective working relationships with all levels of personnel and medical staff.

10. Ability to problem solve and engage independent critical thinking skills.

11. Ability to maintain confidentiality relevant to sensitive information.

12. Ability to prioritize work demands and work with minimal supervision.

13. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

Graduate from an accredited clinical or technical program in Allied Health required. Nebraska licensure as a Registered Nurse with Bachelor's degree preferred. Minimum of three (3) years related clinical experience required. Quality improvement experience preferred.

PHYSICAL REQUIREMENTS:

(Physical Requirements are based on federal criteria and assigned by Human Resources upon review of the Principal Job Functions.)

(DOT) – Characterized as sedentary work requiring exertion up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects, including the human body. #LI-RH1