Summary

Serves as an expert resource to advance Quality and Patient Safety (PS). Supports the management of quality and performance improvement for the organization and its Medical Staff through participation in and coordination of activities related to the acquisition, aggregation, and analysis of relevant data and its use toward improvement of clinical and work processes. Assists in overseeing constant preparedness for Joint Commission, CMS, and other regulatory inspections. Develops, manages, and coordinates the quality, evidence-based care of patients. Strives to ensure evidence-based medicine is used in the treatment of patients. Provides education and leadership on patient floors to drive quality metrics in disease specific areas.

Job description

Summary

Serves as an expert resource to advance Quality and Patient Safety (PS). Supports the management of quality and performance improvement for the organization and its Medical Staff through participation in and coordination of activities related to the acquisition, aggregation, and analysis of relevant data and its use toward improvement of clinical and work processes. Assists in overseeing constant preparedness for Joint Commission, CMS, and other regulatory inspections. Develops, manages, and coordinates the quality, evidence-based care of patients. Strives to ensure evidence-based medicine is used in the treatment of patients. Provides education and leadership on patient floors to drive quality metrics in disease specific areas.

Major Job Functions

Serves as an educator on the patient floors to help drive quality of care and CMS/Leapfrog metrics
Works with Team Leaders, Facilitators, and Members to provide ongoing education related to process, data analysis and tools
Resource in providing monthly reports to the Quality Council/Patient Safety Team, Medical Executive Committee (MEC) and Board of Trustees on Performance Improvement, Patient Safety and Regulatory
Coordinates Hospital wide PI/PS/Regulatory meetings as assigned
Identifies and mitigates patient safety risks and coaches staff/leaders and physicians in safe practices
Uses project management tools as needed to interpret data
Applies lean tools and processes to reduce waste in areas of cost, inventory, labor, and distance
Coordinates Root Cause Analyses and Failure Mode and Effect Analyses as assigned
Demonstrates knowledge of current Joint Commission and CMS standards
Assists with the tri-annual Joint Commission survey within the organization and CMS and DHSR surveys
Stays current with CMS and other regulatory standards related to the Core Measures
Assists multidisciplinary team in developing, implementing, and monitoring systems to ensure transitions of care from acute inpatient phase through follow-up out-patient care
Participates in and supports the Joint Commission DSC process and performance measure compliance
Evaluates interdisciplinary care processes ensuring consistency in the standards of care and practice
Other duties as assigned

Requirements

Bachelor of Science in Nursing required
Current licensure in North Carolina as a Registered Nurse or Compact state licensure
2 years' experience in working with Quality/Patient Safety and Regulatory, Quality Process and/or Data Analysis
Proficiency in reading, writing, and speaking the English language
Knowledge of PI methodologies, Joint Commission and CMS standards, and patient safety issues
Knowledge of quality planning, cost of quality, and importance of documentation
Knowledge of basic statistics, distributions, probability, and measurement scale
Skills with the audit process to include audit types as well as audit roles and responsibilities
Skills in working with teams to include team building techniques and understanding team roles and responsibilities
Ability to collect, aggregate and review data
Nurse Practitioner NP preferred
Experience with regression and correlation, hypothesis testing, design of experiments (DOE) preferred

Benefits

Relocation assistance

Company overview

Cape Fear Valley Health is a comprehensive regional healthcare system based in Fayetteville, North Carolina, serving southeastern North Carolina and surrounding regions. Established in 1956, it has grown to become North Carolina's 8th largest health system, operating as a private not-for-profit organization with 7,500 employees and over 1,000 physicians. The system encompasses eight hospitals with 988 total beds, including Cape Fear Valley Medical Center, Highsmith-Rainey Specialty Hospital, Bladen County Hospital, Hoke Hospital, and Harnett Health facilities. Annually, the system serves more than 1 million inpatient and outpatient visits across its network of over 150 locations. Cape Fear Valley Health specializes in cardiac care, cancer treatment, surgical services, neuroscience, pediatrics, rehabilitation, orthopedics, and behavioral health. The organization has earned numerous national recognitions including Healthgrades Top 100 Hospital for Cardiac Care, IBM Watson Top 50 Cardiovascular Hospital, and The Leapfrog Group Grade-A for Patient Safety. With a mission to provide exceptional healthcare for all patients, the system emphasizes patient-centered care, innovation, and community service while maintaining multiple disease-specific certifications from The Joint Commission.