Employment Type:

Shift:

Description:

Position Purpose

Implements and maintains a compliant and comprehensive organization-wide Quality and Performance Improvement Process to address performance opportunities impacting the quality of care delivery to meet regulatory requirements for Saint Francis Hospital (SFH) and Mt. Sinai Rehabilitation Hospital (MSRH). Partners to perform Root Cause Analysis (RCA) for safety events utilizing the High Reliability Organization (HRO) Healthcare Performance Improvement (HPI) process and procedure for SFH and MSRH. Monitors and accesses PSI 90 cases for improvement action. Participates in Adverse Events investigation of incident and plans for actions to improve performance and eliminate preventable patient harm for SFH and MSRH. Assists the Director of Quality Patient Safety Regulatory Affairs and Patient Relations the Regulatory and Patient Safety Specialist and the Clinical Quality and Patient Relations Coordinator in executing action plans for continuous improvement. Acts as a resource for staff by providing education and assistance regarding performance improvement in quality of care delivery regulatory requirements patient safety and other associated activities.

What you will do

• Facilitate hospital-wide ongoing efforts to address opportunities for improvement directed at continuously building high reliability and safe processes

• Oversee performance improvement activities to ensure mechanisms are in place to prevent avoidable harm and to meet regulatory compliance with the CMS Conditions of Participation Quality Assurance and Performance Improvement (QAPI) program The Joint Commission and the Connecticut Department of Public Health

• Manage the review and compilation of performance improvement activities surrounding safety events precursor safety events and near misses

• Perform RCA and Failure Modes Effects Analysis (FMEA) activities as required

• Support the coordination of investigations into occurrences tracking and completing action plans to address known concerns

• Maintain a log of performance activities and outcomes to meet QAPI directives

• NDNQI collaboration with Nursing Education

• Provide assistance to the organizational high reliability and safety program to sustain safety training and safety habits throughout the organization

Minimum Qualifications

• Connecticut RN license required

• Bachelors degree in related field required; Masters Degree in Nursing Healthcare or related field preferred

• At least five (5) years hospital clinical experience. At least two (2) years experience in a quality/regulatory and/or patient safety/ performance related role.

• Knowledge of regulatory requirements surrounding patient adverse events patient quality of care and safety initiatives and quality indicators

• Certified Professional in Healthcare Quality (CPHQ) preferred

Position Highlights and Benefits

• Full time 40hrs M-F days

• Excellent benefits - starting day 1!

Ministry/Facility Information

Saint Francis Hospitaliscommitted to exceeding the expectations of our patients and families by providing world-class service in a progressive people-centered compassionate health care environment. We are licensed for 617 beds and 65 bassinets are a major teaching hospital and the largest Catholic hospital in New England.

Our Commitment

Rooted in our Mission and Core Values we honor the dignity of every person and recognize the unique perspectives experiences and talents each colleague brings. By finding common ground and embracing our differences we grow stronger together and deliver more compassionate person-centered care. We are an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race color religion sex sexual orientation gender identity national origin disability veteran status or any other status protected by federal state or local law.