Nursing Quality, Risk & Patient Safety Specialist (Full Time)

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives. Reporting to the Director of Quality & Patient Safety, the Quality and Patient Safety nurse specialist plays a role in investigating patient safety incidents, risk management, reviewing publicly reported quality data by reviewing charts in the EMR, reviewing outliers, compiling reports and serving as the liaison with clinical stakeholder and clinical committees in sharing the outcomes of safety incidents and data. In addition to the goal of optimizing performance on the key performance indicators and quality measures, the RN specialist also aims to foster a culture of safety by specifically focusing on high reliability processes to reduce serious safety events and improve patient outcomes. The nurse works with clinical staff to review clinical charts, interpret data, and implement quality improvement initiatives to deliver excellence in clinical care. Job Description: Principal Duties and Responsibilities Oversees the data collection of hospital pay-for-performance programs including but not limited to CMS Inpatient Quality Reporting, Outpatient Quality Reporting, Inpatient Psychiatry, Joint Commission and MassHealth. Reviews medical records to collect data for reporting quality measures, including both concurrent medical record review and periodic medical record review for audit purposes as well as medical record review for serious safety events Trains, coaches, and supports clinical departmental leaders and staff clinical staff in reviewing clinical charts, interpreting quality data, and implement quality improvement initiatives to deliver excellence in clinical care. Provides concurrent monitoring of all externally reported measures and coaching/feedback on outliers. Facilitate use of statistical techniques to analyze data through Medisov, Vizient, Excel, and other database software. Serves as the primary liaison with external measure abstractors who perform primary data abstraction on performance measures including but not limited to Q-Centrix. Provide expert knowledge, leadership, mentoring to patient safety initiatives utilizing safety science and principles of high reliability. Provide hands-on support of quality and safety work to clinicians and teams. Contribute to metric development and dashboard creation and maintenance to reflect the improvement and safety work at Mount Auburn Hospital. Analyze data and prepare concise, accurate, and meaningful quality reports in accordance with quality improvement/management principles. Collaborate with multidisciplinary healthcare teams to rapidly identify risk, employ prevention and risk reduction strategies; assist in the monitoring of patient safety standard compliance. Utilize clinical criteria and aggregates data, in the analysis of quality and patient safety issues and evaluating opportunities for improvement. Conducts surveillance, chart reviews and education activities for patient safety and performance improvement; Participates in data collection, data review, analysis and event reporting. Remains fully informed of evolving national and local quality, patient safety, and risk management mandates and guidelines. Collaborates with persons clinically responsible for inpatient and outpatient departments as well as non-patient care support areas based on interpretation and evaluation of CMS, CDC, OSHA, ODH, APIC, TJC, and EPA guidelines, standards and/or regulations or other standards related to safe and effective patient care. Coordinates implementation of assigned projects, including plans, and keeping improvement teams on track to produce deliverables. Provide expert knowledge, leadership, mentoring to patient safety initiatives utilizing safety science and principles of high reliability. Participates in departmental education, staff meetings, and educational activities as needed. Participates and supports committees such as Medication Reliability, Sepsis, Perinatal committee, collaborative case review committee etc and participates in departmental M&M conferences Provides support in conducting Root Cause Analysis & Apparent Cause Analysis as well as clinical reviews as needed Commitment to Care with Compassion Professional Standards 1. Demonstrate courtesy, respect and presence: Make people feel at home when they wish they were. Be welcoming, approachable, and attentive; acknowledge people immediately. Greet people warmly –with a smile, eye contact, and welcoming words. Introduce yourself and your role; wear your name badge at all times. Ask for and use people’s preferred name. Tune in. Give patients and all other customers your undivided attention. Respect and support others who have different cultures and primary languages. We’re part of a long, proud medical tradition. Look the part. Follow your department’s dress code. 2. Listen and communicate with care: Let your words and deeds say “you matter to me. Communicate your concern, empathy and understanding. Acknowledge feelings. Explain what you’re doing. Tell people what they can expect and why. When someone complains, HEAR. Hear. Empathize. Apologize. Resolve. Connect: Pull up a chair, be at eye level. Look directly at the person. Invite questions and check your understanding and theirs. Make sure you understand each other in person and on the phone; find a coworker or interpreter if you need help. 3. Reach out and offer help: Don’t just react. Act first. Help people find their way. Take them there. Treat all patients, family members, and guests as your priority. Stop what you’re doing to acknowledge their presence. Anticipate people’s needs and help before they have to ask. Don’t think, “It’s not my job.” Help or find someone who can. Offer help in a way that protects each person’s dignity. Put people at ease. Reach out and extend a few words of concern. Ask, “Is there anything else I can do for you?” 4. Take care of our environment: Help to build confidence in us and promote calm and healing. Keep it neat and professional. Stop to pick up trash and toss it out. When you see a spill or other safety hazard, correct or report it immediately. Keep the noise down. When you’re ill or busy, noise annoys. 5. Consider and support coworkers: Through teamwork, cooperation and respect, we make each other stronger. Connect to fellow employees. Say hello and show warmth. Promote and speak positively of each other. Build our patients’ confidence in our whole team. Respect coworker privacy. Avoid gossip and the temptation to criticize. Invite and consider others’ ideas and views. Give others credit and regard. Express appreciation and thanks. Make sure your coworkers can rely on you. Be on time and on task. Respect each others’ cultures and the dignity of each individual. Give feedback to coworkers directly, caringly and privately. Pitch in to help. Team with people in other departments. Get to know them. Help them understand your role. Collaborate for the sake of our patients. 6. Use respectful telephone etiquette: When you’re on the phone, our reputation is on the line. Make every effort to answer on or before the third ring; help each other answer phones. Speak clearly and politely. When you answer the phone or use voicemail, start with a hello, your name and department, and “How may I help you?” Ask permission to place a caller on hold and wait for their response. Return as fast as possible. Don’t let them feel forgotten and thank them for holding. When transferring a caller, make sure the caller reaches their desired destination. Offer them the number before transferring call. Return calls promptly, within 24 hours or less. When leaving a message, include your number and the best time to reach you. 7. Respect people’s time: When people are waiting, every minute is an hour. Respond to call bells quickly, showing a sense of urgency. Strive to serve people on time. Keep people up-to-date on wait times. Adjust their expectations with accurate information. Update people who are waiting—at least every 15 minutes. Update families at least hourly when a patient is involved in care. Anticipate delays. Inform the patient ahead of time and offer options. Offer comforts while people are waiting. Apologize for delays; and avoid blaming others. Thank people for waiting. 8. Handle difficult situations with kindness and compassion: Listen and ease the person’s way to satisfaction and solutions. When someone complains, listen—don’t be defensive or take it personally. Show understanding without judging. Apologize genuinely for inconvenience or discomfort. Take corrective action and offer options. If you’re unable to resolve a situation, find a manager who can. 9. Protect confidentiality and privacy: It’s a matter of respect and the law. Protect modesty and dignity. Knock before entering. Always introduce yourself by name and title. Close curtains. Cover people up. Wait for the next elevator or take the stairs if an elevator is occupied by a patient. Watch what you say and where you say it. Share private information only with people who have a job-related need to know. Keep personal conversations away from patients and families. Carefully follow Mount Auburn Hospital’s confidentiality and privacy policies for the sake of patients and each other. Organizational Responsibilities 1. Follows hospital and department policies with special attention to safety, dress, attendance and punctuality, and display of ID badge. Subscribes to hospital’s mission statement, code of ethics, and standards of conduct. 2. Handles all work-related information in a confidential manner, as outlined in Confidentiality Policy. Recognizes and respects each patient’s right to privacy, and understands that this is protected by statute. Understands that looking up patient information not needed for job duties is prohibited and may be grounds for immediate dismissal. 3. Demonstrates initiative and creativity to continuously improve services, departmental and interdepartmental processes, and any other activities that affect quality. 4. Plans, organizes, and renders care for (neonate, pediatric, adolescent, adult, geriatric) patients within an assigned area. 5. Performs work responsibilities while staying in compliance with all applicable laws, rules, and regulations. Understands and agrees to uphold the Hospital Compliance Plan. 6. Adheres to Bloodborne Pathogen Exposure Control plan including consistent use of safety devices as designed to prevent sharp injuries. Patient Safety 1. When taking a telephone order, writes the order on the Doctor’s Orders, reads the order back to the MD and document as a TORB. 2. When taking a verbal order, repeats the order back to the MD prior to implementing the order and documents as a VORB. 3. Uses only accepted abbreviations when documenting in the medical record. 4. Uses two unique patient identifiers prior to treatment or patient transport. 5. Adheres to Safe Injection Practices i.e. never reuses needles, cannulae and syringes. 6. Complies with Isolation Precautions including standard precautions; i.e, dons and removes appropriate personal protective equipment (PPE) as required by specific patient precautions. 7. Consistently complies with the hospital's Hand Hygiene Policy, i.e. cleans hands before every patient contact (even if gloves are worn), before donning sterile gloves for aseptic task, after handling body fluids, after every patient contact, and after contact with patient's environment. 8. Participates in EHS's TB program. 9. Participates in hospital's annual seasonal vaccine program (vaccination or declination completed). *Development plan on record. KNOWLEDGE, SKILLS, AND ABILITIES REQUIRED 1. R.N. with experience in risk management, quality assessment, or utilization management. 2. Strong spreadsheet, database, and word processing skills in order to maintain effective computerized incident reporting systems and provide detailed reports to groups on a regular basis. Microsoft Office skills to include Word, Excel, Access, Powerpoint, Project and Sharepoint. Fluent with EHR and data entry systems (electronic medical records, electronic health records). Experience with Epic a plus. 3. Superior interpersonal communication skills in order to work effectively with a variety of individuals, including physicians, administrators, nurse managers, outside regulatory organizations, insurance companies, and support staff. 4. Superior writing skills to prepare various reports to state and federal regulators, insurance appeals, internal correspondence, and clinical summaries for medical peer review. 5. Excellent understanding of clinical aspects of care. Applies knowledge of disease and nursing processes to write effective appeals and clinical abstracts, identifies quality of care and risk management issues. Uses clinical knowledge to assess whether the level of care was rendered was at appropriate level (inpatient vs. outpatient). 6. Analytical skills to interpret and apply clinical and regulatory requirements to individual cases. Ability to quickly and accurately abstract and communicate clinical information from the medical record and supporting documents. 6. Experience with QI tools including PDSA cycles, process mapping, fishbone diagrams etc 7. Excellent organizational skills to prioritize and manage multiple responsibilities on a daily basis. Independently sets priorities. 8. Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Quality (CPHQ) Preferred. WORKING CONDITIONS 1. Normal hospital environment 2. Performs data entry with repetitive hand movement and visual concentration at video display terminal in order to review and enter data. Mount Auburn Hospital employees must be able to readily adjust to change and handle a rapid-paced environment and the stresses associated with that, while continuing to provide high-quality, efficient service. Pay Range: $73,112.00 USD - $188,448.00 USD The pay range listed for this position is the annual base salary range the organization reasonably and in good faith expects to pay for this position at this time. Actual compensation is determined based on several factors, that may include seniority, education, training, relevant experience, relevant certifications, geography of work location, job responsibilities, or other applicable factors permissible by law. As a health care organization, we have a responsibility to do everything in our power to care for and protect our patients, our colleagues and our communities. Beth Israel Lahey Health requires that all staff be vaccinated against influenza (flu) as a condition of employment. More than 35,000 people working together. Nurses, doctors, technicians, therapists, researchers, teachers and more, making a difference in patients' lives. Your skill and compassion can make us even stronger. Equal Opportunity Employer/Veterans/Disabled At Beth Israel Lahey Health, we are driving the change in health care that Massachusetts wants and needs. Our culture promotes continuous learning, growth, innovation and a sense of belonging. We make it a priority to offer comprehensive compensation and benefits and help you achieve a healthy and balanced life. While you're busy caring for and supporting our patients, we take care of you.