CQSP-RN

Position Title: Clinical Quality & Safety Program Manager-RN (CQSP)

Department: Hospital and Emergency Services

Reports to: Hospital DON and Medical Director

Monitors: RNs/LPNs/CNAs

Wage & Hour Status: Non-exempt, 8-12 hour shifts

Qualifications

• Completion of an accredited Associate’s or Bachelor’s degree in nursing, Bachelor’s degree preferred.
• Current licensed as a Registered Nurse in Minnesota
• Three years clinical RN experience in trauma/emergency care recommended
• 1 year of infection prevention and quality improvement program experience recommended
• Must be certified in Basic Life Support (BLS) upon hire or within 3 months of hire
• Must be certified in Advanced Cardiac Life Support (ACLS) and Pediatric Advanced Life Support (PALS) upon hire or within 6 months of hire
• Must be certified in Trauma Nursing Core Course (TNCC) or Comprehensive Advanced Life Support (CALS) upon hire or within 1 year
• Ability to establish and maintain effective interpersonal relationships.
• Ability to accept and implement change.
• Ability to problem solve and make decisions.
• Possession of critical thinking, analytical, teaching/coaching and research skills.

Nature and Scope

The Clinical Quality & Safety Program Manager serves as the primary outpatient nurse to prioritize the coordination and delivery of safe, timely, and efficient outpatient services. The CQSP is responsible for developing, implementing, and maintaining compliance programs and maintaining a cost-effective system of care for trauma patients and their families throughout the continuum of care, coordinate and support organization-wide quality improvement, infection control, and workplace violence program activities,. The CQSP works independently and in collaboration with the director of nursing, medical director, providers, administration, and clinical staff. The CQSP will be part of the acute care RN pool.

The acute care RN will deliver care to patients utilizing the nursing process of assessment, planning, intervention, implementation, and evaluation to care for all types of patients presenting to the emergency department or admitted to the hospital. The acute care RN has the ability to prioritize, recognize, and respond quickly to the ever-changing patient condition and needs. The acute care RN is responsible for collaborating with the interdisciplinary team to develop an appropriate and safe plan of care for the patient.

Principle Duties and Responsibilities

Administration

• Support and adhere to hospital policies, procedures, philosophy and mission.
• Produce and manage the programs budgets.
• Interpret, develop and implement policies and procedures; make recommendations for revisions; assist with updating policies and procedures.
• Participate in the development and planning of goals and objectives related to trauma care, quality improvement, infection control and workplace violence.
• Coordinate with the director of nursing, medical director, hospital administration and clinicians to assess the need for policies, procedures and protocols relating to the care of trauma patients, quality improvement, infection control, and workplace violence.
• Represent the trauma, stroke, quality improvement, infection control and workplace violence programs on various hospital and community committees to enhance and foster optimal trauma care management, quality improvement initiatives, infection control practices and workplace violence requirements.
• Anticipate trends and future needs of these program.
• Supervise adherence to hospital policies and procedures and standards through observation, medical record review, staff feedbacks and other appropriate sources.
• Serves as a liaison to administration, representing these programs on various hospital and community committees to enhance and foster fiscally sound programs.

Outpatient Therapy Services

• Coordinate outpatient patient care, including scheduling, clinical preparation, treatments, infusions, injections, procedures, and follow-up as applicable.
• Review outpatient orders for completeness and facilitate clarification of incomplete or unclear orders prior to providing services.
• Coordinate with providers, pharmacy, nursing, prior authorization staff, referral sources, and other departments to prevent unnecessary delays in patient care.
• Monitor incoming outpatient requests, referrals, telephone calls, and faxed orders to ensure they are addressed and routed appropriately.
• Identify barriers that may delay outpatient treatment and proactively communicate with the appropriate department or provider to facilitate resolution.
• Ensure required medications, supplies, equipment, documentation, and authorizations are available prior to scheduled outpatient services when applicable.
• Perform appropriate nursing assessment, monitoring, documentation, patient education, and follow-up related to outpatient services.
• Recognize changes in patient condition and initiate appropriate clinical intervention or escalation.
• Maintain effective communication with patients regarding scheduling, treatment expectations, follow-up needs, and changes in the plan of care.
• Outpatient nursing responsibilities are a priority function of this position and shall be appropriately balanced with Trauma, Stroke, Quality Improvement, Infection Prevention and Control, and Workplace Violence Prevention program responsibilities to ensure direct patient-care needs are addressed safely and without unnecessary delay.

Trauma Program Initiatives

• Implement program initiatives.
• Monitor and maintain compliance with statewide trauma system regulatory requirements.
• Coordinate preparation for statewide trauma system designation site visit.
• Develop and foster collaborative relationships with all hospital departments to facilitate and support quality trauma care.
• Participate in state and regional trauma care activities
• Monitor national and statewide trends in trauma care.
• Respond to trauma team activations that occur during work hours; function in whatever role necessary to assist the team in the care of the patient.
• Serve as a resource for the hospital staff regarding trauma care issues.
• Plan and implement strategies for ongoing trauma program development and improvement.
• Monitor state and national trends in trauma care.
• Collaborate with trauma program medical director, physicians and other health care professionals to provide clinical and system oversight for the care of trauma patients, ensuring the provision of efficient, quality, cost-effective care.

Quality Improvement/Performance Improvement Initiatives

• Collect, analyze, trend, and report quality and patient safety data to identify opportunities for improvement.
• Coordinate multidisciplinary review of quality concerns, adverse events, and identified trends.
• Assist departments with development, implementation, monitoring, and evaluation of performance improvement plans.
• Facilitate root cause analysis and other structured reviews as appropriate.
• Monitor effectiveness of corrective actions and improvement initiatives.
• Collaborate with leadership, medical staff, nursing, and other departments to promote evidence-based, safe, and high-quality patient care.
• Assist with regulatory, accreditation, and survey readiness activities related to quality and patient safety.
• Assess and improve departmental performance.
• Maintains quality control programs and participates in the organization's overall quality control program.
• Monitor performance of hospital staff involved with the care of trauma patients.
• Monitor trauma patient outcomes; evaluate for trends.
• Coordinate with physicians, nurses, other in-hospital staff and outside providers to evaluate and address specific patient care issues.
• Participate in case review.
• Assist the trauma program medical director and hospital administration in the development, implementation and evaluation of a quality plan which is multi-disciplinary and patient-outcomes focused.
• Serve as the coordinator for the identification, investigation, reporting and follow up of incidents and quality issues throughout the program while maintaining confidentiality.
• Monitors the trauma team's availability and compliance with policies and standards.
• Develop and monitor the trauma PI program in collaboration with the trauma program medical director or trauma program co-advisor.
• Coordinate and schedule the multidisciplinary review meetings.
• Assists in data collection related to the trauma patient.
• Analyze registry data on the trauma patient population; identify trends for strategic planning and performance improvement.
• Manage registry data: collect, analyze and trend.
• Supervise the collecting, coding, scoring and developing of processes for validation of data entered into the registry.
• Ensure accurate data entry into the trauma registry.
• Ensures the maintenance of the trauma registry in collaboration with the trauma registrar.
• Ensure the periodic reporting of trauma data to the state trauma program.
• Facilitate the measurement of selected outcomes for the trauma patient population.

Infection Prevention Program Initiatives

• Coordinate the organization's infection prevention and control program in collaboration with the director of nursing, medical staff, nursing, and other departments.
• Conduct surveillance for healthcare-associated infections and other reportable or significant infection trends.
• Collect, analyze, trend, and report infection prevention data.
• Monitor compliance with infection prevention practices, including hand hygiene, isolation precautions, use of personal protective equipment, and other established infection-control measures.
• Investigate potential healthcare-associated infections, exposures, outbreaks, and infection-control concerns.
• Coordinate appropriate follow-up and corrective actions related to identified infection prevention risks.
• Develop, review, and update infection prevention policies and procedures.
• Collaborate with applicable public health agencies and regulatory organizations as required.
• Participate in infection prevention risk assessments and development of the organization's infection prevention plan.

Workplace Violence Program Initiatives

• Coordinate the organization's workplace violence prevention program.
• Assist in developing, implementing, reviewing, and updating workplace violence prevention policies, procedures, and response plans.
• Track, investigate, analyze, and trend workplace violence incidents and staff safety concerns.
• Identify patterns and opportunities for risk reduction and recommend corrective or preventive actions.
• Collaborate with administration, nursing, human resources, security/law enforcement, and other departments regarding workplace violence prevention and response.
• Coordinate staff education regarding workplace violence prevention, recognition, de-escalation, reporting, and response procedures.
• Facilitate or participate in multidisciplinary review of workplace violence events.
• Monitor implementation and effectiveness of workplace violence prevention initiatives.
• Promote a culture that encourages timely reporting of threats, assaults, and safety concerns.
• Assist with workplace violence risk assessments and development of mitigation strategies.

Clinical Education

• Plan, coordinate and evaluate trauma, QAPI, IP and WPV-related educational programs for nursing staff.
• Monitor providers and nurse compliance with the educational requirements of these programs.
• Ensure staff involved in the care of trauma patients meet educational requirements of the trauma program.
• Develop, coordinate and implement orientation, nursing education, and in-service programs related to care and management of trauma patients.
• Seek and pursue opportunities for internal and external trauma-related educational programs for hospital staff.
• Provide education regarding quality improvement, patient safety, and applicable regulatory requirements.
• Provide infection prevention education and serve as a resource to staff.

Community Outreach

• Collaborate with EMS in the development and implementation of an injury prevention program.