Quality and Safety Excellence Nurse: MIPS Coordinator

Job Title

Employment Type: Full time

Description:

Essential Functions

Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) Mission, Vision, Core Values, Actions and Promise in behaviors, practices, and decisions.

Assists the manager in areas of oversight of quality, patient safety (inclusive of the culture of safety (TogetherSafe) work) and infection prevention across the ministry.

Supports the work of quality and safety related to the quality assurance and performance improvement plan, local/region/system strategies, regulatory and accrediting body requirements (i.e., Centers for Medicare and Medicaid Services (CMS), Iowa Department of Inspections and Appeals (IDIA), The Joint Commission (TJC), etc.), in conjunction with the hospital's leaders, colleagues and providers.

Identifies problem areas in need of focused attention and supports the manager to implement actions to drive improved outcomes.

Assists the manager in achieving the best outcomes aligned to CMS, pay for performance programs (including those aligned to commercial carriers) and TJC in areas of quality measures and regulatory requirements.

Promotes continuous improvement toward achieving excellent outcomes and recognition in regards to outside "rating" organizations, including (not all inclusive) CMS, Leapfrog, Healthgrades, and Blue Distinction etc.

Collaborates with Medical Group executive leadership, providers, and leaders in meeting/exceeding standards of excellence and achieving national designations, certifications, and awards.

Collaborates with colleagues in areas of accreditation, risk management, patient experience, clinical practice and performance excellence to provide identified and needed support for improvement.

Serves as a resource for Clinic Operations and Clinical Leaders in the development, implementation, and evaluation of patient care programs and clinic practice standards, including policies, guidelines, procedures and professional practice models.

Facilitates and supports the local market Medical Practice Committees.

Assists with implementation of quality excellence systems that integrate LEAN and other methodologies as appropriate to create a data-driven quality improvement programming.

Provides appropriate support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams.

Works closely with colleagues in improving the organization's culture of safety - including the concept of a "Just Culture" and "TogetherSafe".

Supports opportunities for improvement on Cause Analyses (apparent cause, root cause, common cause), Healthcare Failure Modes and Effects Analysis (HFMEA), and Patient Safety Organization (PSO) initiatives.

Assists the manager in ensuring accuracy of data in regulatory and accrediting quality databases (i.e., CMS HARP, TJC), registries, and dashboards/scorecards for internal and external customers.

Promotes an environment of shared leadership, decision-making and accountability.

Maintains a working knowledge of applicable Federal, State, and local laws and regulations, Trinity Health's Organizational Integrity Program, Standards of Conduct, as well as other policies and procedures in order to ensure adherence in a manner that reflects honest, ethical, and professional behavior.

Supports organizational evidence-based practice, innovation and research.

Assists the manager in the clinical contracting process, consistent with legal and regulatory requirements.

Contributes to the quality process in evaluating provider performance, inclusive of the focused and ongoing professional practice evaluation review process.

Maintain awareness of and respond to issues in areas including the following:

• Ethnic, cultural and diversity changes in the population
• Political and social influences
• Financial and economic issues
• The aging of society
• Ethical issues related to healthcare

Perform other duties consistent with the purpose of the job as directed.

Minimum Qualifications

Education:

• Bachelor's degree in nursing, health administration or related field required.
• Or in active pursuit of a Bachelor's degree.

• Iowa licensure as a Registered Nurse.

Experience:

Requires a minimum of three (3) years in clinical setting (ambulatory setting preferred).

Special Skills, Competencies, and Aptitudes:

Member of a professional healthcare organization.

Demonstrated expertise in the use of performance improvement methodology/tools.

Must be able to use computers for documentation and other relevant activities. Demonstrates specific knowledge related to software programs such as event reporting systems, government reporting systems, and other appropriate software programs. Experience with computer applications such as Microsoft Office Suite (Word, Excel, PowerPoint, Outlook), HealthStream, Intranet, and use of reporting tools. Helpful to have experience with PowerChart/EPIC or similar tool.

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.