RN - Quality Process

Responsible for Socorro General Hospitals Quality Program including Clinical Quality, Patient Safety and Regulatory/Accreditation compliance. Plans, develops, coordinates, implements and evaluates quality management processes. Leads the development of facility measures (Performance Measurement scorecards and dashboards). Uses data display and statistical tools to interpret data for decision making. Interfaces with SGH departments and PHS entities to gather, measure, analyze, and interpret data from multiple sources in support of clinical programs in patient safety and clinical quality. Prepares and presents data interpretation and recommendations to clinical programs and to appropriate committees and groups. Leads or directs in identifying, designing and documenting appropriate analytical solutions by defining, creating, evaluating and selecting or recommending appropriate alternatives. Develops quality improvement solutions in a variety of settings with highly variable/diverse groups of individuals. Advises and educates in the design and development of sampling mechanisms used for various initiatives. Provides support with database and spreadsheet development along with the needed infrastructure maintenance. Serves as a resource/educator to other employees regarding data collection, action plan development, database and spreadsheet use and maintenance. Serves as resource/educator to other employees regarding application of computer technology to the work of continuous quality improvement and patient safety. Demonstrates excellent verbal and written communication skills, including the ability to speak and write clearly, concisely, and target communication to both technical and non-technical audiences. Ability to effectively express technical concepts both verbally and in writing. Coordinates project data analysis in support of initiatives that are prioritized by the SGH Quality/Patient Safety/Regulatory Committee and identified in the Quality Plan. Uses established quality and process improvement methods, techniques and tools to document and maintain all deliverables created in accordance with department policies. Facilitates and leads the development and deployment of action plans or projects utilizing appropriate quality, process improvement, and project management tools. Works in a team environment, take and give direction and follow through, compromise, negotiate and achieve consensus decisions, support consensus decisions, be flexible and adaptable to changes in assignments and the work environment, work independently, manage time efficiently and multi-task effectively. Facilitates access to data for clinical program administrators, medical directors, and others needing information. Assumes oversight and facilitates the OPPE/FPPE and Medical Staff peer review process. Responsible for the oversight of patient safety issues, conducts sentinel/serious clinical event investigation (Patient Safety Investigations) and root cause analysis of events and reports clinical event investigations to the appropriate committees. Working with the Director of Regional Quality and Director of PDS EOC and Accreditation and Regulatory Readiness ensures a campus wide effective preparation and response program that meets Regulatory and Accreditation standards, including the provision of appropriate training. Supports development of automated routine reports for population of data for internal and external reports and performance scorecards. Functions as an effective contingent member - attends Quality, Patient Safety and Regulatory meetings to include: Clinical Outcome Committee (COT), Regional Quality Meetings, Patient Safety Investigation (PSI) team meetings, SCERT Committee meeting as appropriate, PDS-CRP committee, SGH Board Quality meeting and the SGH Board. Represents SGH on the Presbyterian Clinical Excellence Network and process management committees. Other duties as assigned.