ResponsibilitiesNebraska Spine Hospital is a 34 bed, spine specialty hospital. As the region's only Spine center of excellence, Nebraska Spine Hospital's mission is to provide the highest quality care, through cost effective and patient focused services. All teammates are eligible to participate in a facility incentive program. If you are interested in joining a family atmosphere while being a part of a high performing team, Nebraska Spine Hospital is for you.
Lead, facilitate, and advise the Center Quality Council and internal performance improvement teams:
- Set the agenda and maintain meeting minutes
- Ensure reporting of all mandatory and center specific monthly and quarterly reports for trends/areas for improvement to the Quality Council and Medical Executive Committee/Governing Body a minimum of quarterly:
- Medical Record Audit reports; Monthly or quarterly data collection from ongoing systematic chart review to assess quality of documentation.
- Infection Control reports
- Hospital Transfer/Complication reports
- Patient Safety; measurement of key measures of patient safety and hazard analysis/process redesign (adverse events, root cause analysis).
- Life safety (environment of care); Provide for a detailed assessment and evaluation of the Environment of Care (EOC) and the associated conditions, staff education and readiness and the various processes. Framework for the EOC includes the management processes and systems that affect safety, security, hazardous materials, emergency preparedness, life safety, medical equipment, and utilities management.
- Risk Management (incident reporting)
- Adverse Drug Reaction reports
- Cancellation logs
- Service Satisfaction reports (patients, staff and physicians)
- Center specific quality indicator reports as appropriate
- PI reports; Collection, analysis and summary of performance improvement data.
Provides strategic oversight of proactive and reactive patient safety activities:
- Root cause analysis.
- Clinical practice guidelines
- Sentinel Event Alerts
- Identification and data collection of center specific quality indicators based on high risk, problem prone procedures as appropriate.
- Review and revision of the PI Plan on an annual basis and preparation of the annual report of the PI program to the Medical Executive Committee/Governing Body.
- Documentation of all Performance Improvement activities and maintenance of records for a minimum of three years.
Provides strategic oversight of proactive and reactive patient safety activities (continued):
- Coordination of the center policies/procedures and processes to be in compliance with the current standards of applicable regulatory and accrediting agencies, and mandatory SCA Corporate policies.
- Working with the Administrator/designee to ensure currency of all physician files, medical staff appointments and/or privileges and compliance with credentialing policies and procedures. Coordinating as appropriate the peer review process and aggregate individual peer review data for presentation and review by the Medical Executive Committee and Governing Body at reappointment.
- Working with the Administrator/designee to ensure currency and completeness of all human resource and education files for center employees and contract personnel.
Maintain Center Survey readiness:
- Assess center compliance with accreditation standards and regulations in collaboration with leadership and staff.
- Identify areas of vulnerability and direct the development of strategies to enhance compliance.
- Provide the overall direction necessary to ensure that clinical services provided are evidence-based, in accordance with standards established through state and federal regulations and applicable accreditation standards, including the National Patient Safety Goals.
Communicate Effectively Throughout All Levels of the Organization:
- Proactively educate and train the leadership and staff regarding regulatory issues, new statutes/guidelines, and safety/quality/performance improvement activities and their respective responsibilities in carrying out the performance improvement program.
- Maintain effective communication on current center activities related to Safety/Quality/PI and Accreditation and seek consultation as needed for support from the Regional Quality Coordinator or assigned Group Director.
Other duties as assigned by Center Administrator.
QualificationsLicenses or Certifications: Licensed Registered Nurse
Education, vocational training, and experience: - Registered Nurse with training and experience in quality/performance improvement and accreditation and regulatory standards.
- Minimum of an Associate's degree in nursing, Bachelor's degree preferred
- Work in concert with the Regional Quality Coordinator to implement the SCA strategic clinical-quality plan.
- Possess excellent written and oral communication skills.
- Knowledge of standards, survey methodology and related tools and resources for regulatory and accreditation requirements
- Regularly accesses internal and external resources to maintain professional knowledge base.
USD $41.00/Hr. USD $59.00/Hr.
