Quality & Clinical Review Nurse

Position Summary

Under general direction, the Quality & Clinical Review Nurse is responsible for the daytoday coordination and oversight of the organization’s Stroke and Sepsis Programs. This role ensures comprehensive, evidencebased care for stroke and sepsis patients, supports ongoing program performance, and drives compliance with regulatory and accreditation standards. The Specialist facilitates multidisciplinary collaboration, monitors key quality metrics, and leads initiatives that enhance clinical outcomes and patient safety.

In addition to program coordination, this position plays a key role in organizational quality review processes. The Quality & Clinical Review Nurse conducts and supports mortality reviews, anesthesia peer reviews, and patient care reviews, ensuring timely evaluation, accurate documentation, and effective followup on identified opportunities for improvement. Through expert clinical knowledge, data interpretation, and partnership with medical staff and leadership, the Quality & Clinical Review Nurse contributes to the continuous improvement of patient care, clinical performance, and overall quality outcomes.

Program Coordination & Clinical Quality Oversight

• Oversees the daytoday coordination of Stroke and Sepsis Program activities under general direction.
• Monitors program performance metrics, identifies trends, and collaborates with clinical teams to improve outcomes.
• Supports compliance with all regulatory, accreditation, and certification requirements (e.g. CMS, DNV).
• Ensures program policies are aligned with legislative regulations, accreditation standards, and evidencebased practices.
• Facilitates multidisciplinary meetings, case reviews, and performance improvement initiatives related to stroke and sepsis care.
• Tracks, trends, and reports program and review outcomes to appropriate committees and leadership groups.
• Represents the Stroke and Sepsis Programs in internal committees, work groups, and external surveys or audits.
• Coordinates ACT (Acute Clinical Team) data collection, ensuring accurate documentation, timely submission, and integration of findings into quality improvement initiatives.
• Monitors medical emergency response trends and collaborates with clinical teams to address systemlevel improvement opportunities.
• Serves as the point person for questions, policy revisions, and performance monitoring for the Fall Program, including ongoing review of HD fall data for continuous improvement.

Clinical Review Processes

• Conducts and supports mortality reviews, ensuring timely case identification, data collection, and documentation.
• Coordinates anesthesia peer reviews, including case selection, review preparation, and followup on action items.
• Supports patient care reviews to evaluate clinical quality, identify improvement opportunities, and support corrective actions.
• Collaborates with medical staff leadership, quality teams, and department leaders to ensure consistent review processes and effective communication of findings.
• Conducts medical emergency reviews (e.g., ACT calls, code events), including case identification, data abstraction, facilitation of multidisciplinary review, and tracking of action items.
• Aligns medical emergency review processes with existing clinical peer review standards to ensure consistency, fairness, and systemlevel learning.

Education, Training & Staff Support

• Provides education to staff on program standards, clinical pathways, and best practices for stroke and sepsis care.
• Offers education and feedback to clinical teams based on review outcomes and program needs.
• Ensures completeness of unitbased orientation for new employees and annual education for existing employees related to stroke prevention and care.
• Develops educational programs for hospital staff, medical staff, patients/families, and the community on stroke conditions, early recognition, treatment modalities, and prevention.
• Develops and maintains a library of resources for patients, families, and staff related to stroke conditions, prevention, treatment, and emerging technologies.
• Provides education related to ACT processes, medical emergency response expectations, and improvement opportunities identified through review activities.

Stroke/Sepsis Program–Specific Responsibilities

• Ensures comprehensive care of Stroke Program patients and supports overall program performance and effectiveness.
• Participates in interagency groups and community resources as needed to support stroke awareness and care coordination.
• Participates in the development of department action plans in response to employee, patient, and medical staff survey results.
• Ensures continuous readiness for accreditation surveys and compliance with DNV stroke standards.
• Provides input into the development and communication of policies, procedures, programs, and services related to stroke care.
• Supports strategies that align organizational marketing efforts with the goal of being the regional health network of choice for stroke care.
• Promotes awareness of healthcare trends and issues relevant to stroke and sepsis care.

Collaboration, Communication & Customer Service

• Builds strong working relationships with nursing, physicians, ancillary departments, and leadership.
• Communicates program updates, review findings, and improvement initiatives clearly and effectively.
• Establishes and maintains liaison with medical staff and allied health professionals to support improved patient care.
• Instills a culture of customer service by emphasizing responsiveness, resourcefulness, followthrough, accuracy, timeliness, and accountability.

Required Qualifications (Including any licensure, certification, education):

• Licensed as a Registered Nurse and authorized by the State of Iowa to practice nursing or has active multistate license approved by the Nurse Licensure Compact.
• Achievement of Baccalaureate degree in nursing or degree in progress
• Basic Life Support (BLS) training, or within 90 days of hire and must maintain throughout employment.
• Mandatory Reporter training or within 90 days of hire and must maintain throughout employment.

Preferred Qualifications:

• Professional certification in nursing specialty.

Required Knowledge, Skills & Experience:

• Minimum of 3 years RN experience.
• Proficient in communication skills.
• Ability to pursue and foster a sense of team and partnership across all disciplines.
• Ability to communicate effectively, in English, with diverse population groups.
• Ability to be self-directed, flexible, and able to adapt to change.
• Ability to communicate effectively in a professional and tactful manner with physicians, staff, patients and/or their representatives.
• Ability to read and understand chart documentation.
• Ability to demonstrate basic computer skills.
• Ability to read, write and understand the English language.

Preferred Knowledge, Skills & Experience:

• Experience coordinating or supporting Stroke, Sepsis, or other timesensitive clinical programs.
• Ability to analyze clinical documentation and identify opportunities for improvement.
• Experience developing and delivering clinical education, especially related to stroke, sepsis, or emergency response.
• Ability to create learning materials, competencies, or training resources for staff and community audiences.
• Strong relationshipbuilding skills across nursing, physicians, and ancillary departments.