This position is responsible for the coordination of performance improvement, continuous regulatory readiness, and patient safety activities for Nemours Children's Health, Florida which includes the Hospital, satellite locations, affiliate operations and other locations as assigned. Responsibilities include direct participation in the collecting, organizing, compiling, documenting, and analyzing data from a variety of sources to produce reports from which opportunities for quality/safety improvement, intervention and educational activities can be identified. This individual will participate in the collection of data from medical records, logs, databases and error reporting systems that support performance improvement, patient safety, and regulatory readiness activities of the Hospital and the Practice. Assists with education of staff in performance/quality improvement and patient safety concepts, processes, and tools as needed within the scope of these responsibilities. Utilizes the quality methodology in training departments and multi-disciplinary teams. Collaborates with Hospital, Practice, and Medical Staff leadership and key committees to develop long-range goals, objectives, and strategies for quality/safety improvement. Facilitates teams as necessary to achieve performance improvement and continuous regulatory readiness within the organization. Coordinates and conducts evaluation of hospital and medical staff processes via Tracer Methodology to support compliance with state, federal and other regulatory agencies' standards.

Position Responsibilities

• Serves as a key Quality Improvement resource to support both hospital and practice wide initiatives, as well as departmental quality improvement teams, programs, projects, and initiatives. This support includes but is not limited to the following:
  • Partner with department leaders & quality improvement teams to develop and advance the following: Improvement teams' charters; implementation plans; timelines; milestones to effectively track deliverables; performance dashboards; change proposals and other relevant materials needed to support the teams.
  • Assist in coordination, preparation and planning for the projects including: conducting the necessary workshops, implementation of the recommendations, follow up utilizing daily management, and coaching leaders throughout the project.
  • Provide subject matter expertise, education, and consultative support.
  • Conduct current state analysis for priority workflows based on performance gaps. Develop respective gap closure quality improvement plans.
  • Guides data collection, and the preparation of progress reports and outcomes to key stakeholders
• Partners with the Nursing Councils, and appropriate committees as a primary member, from Q/S team, and the chair to support the objectives and priorities of the committee. This support includes organization of committee logistics such as: assist with the preparation of the agenda, participant involvement, completion of items requiring follow-up etc.
• In collaboration with the quality improvement team(s) support the development, upgrade, and delivery of quality improvement training programs and problem solving methodologies/tools, to QI teams and other stakeholders as needed.
• Apply appropriate quality improvement and safety analytical tools and methodologies to identify improvement opportunities and advance rapid cycle improvement (i.e. PDSA, FMEA, SPS Bundles, reliability science, process flow mapping, dashboards utilization, key driver diagrams, run charts and documentation from PDSA cycles implementation, etc.).
• Develop trust and effective working relationships with key stakeholders (quality and safety team, infection prevention, hospital and ambulatory operations).
• Supports continuous readiness activities in preparation for and during regulatory agency surveys.

Position Requirements

• Bachelors Degree required; Masters preferred
• RN or Certified Professional in Healthcare Quality (current or within 2 years). Other healthcare related degree/certification considered.
• Minimum of 3 years experience required