Quality Review Rn / Sepsis Program Coordinator

When you join the growing BILH team, you're not just taking a job, you’re making a difference in people’s lives.

Job Type:

Regular

Scheduled Hours:

40

Work Shift:

Day (United States of America)Quality Review RN / Sepsis Program Coordinator
Position Summary: 
Under the direction of the Quality Director for Quality and Performance Improvement Quality Review RN / Sepsis Program Coordinator plays a vital role in the development, evaluation, and implementation of the organizational Sepsis Program(s) and initiatives. This role will be responsible for leading and facilitating the development, implementation, and ongoing adherence to the identification and treatment of the septic patient population. This position will also support the collection, compilation, and presentation of Sepsis related processes and outcomes data.

Job Description:

Primary Responsibilities

• Serves as a liaison with other quality teams including Safety and Quality Improvement, Medical and Patient Care services, Clinical Documentation Integrity, Senior Leadership at facility and system levels, medical staff, nursing staff, information services, clinical laboratory, Infection Prevention, Antimicrobial Stewardship and others as needed.
• Coordinates the development and evaluation of the organization’s sepsis bundle and control strategies, policies/procedures, and planning.
• Educating staff on sepsis protocols, implementing evidenced-based practices, and ensuring that sepsis care guidelines are followed.
• Collects, presents, and performs analysis, interpretation, and dissemination of sepsis data. This includes risk assessment, surveillance priorities, and outcomes analysis.
• Monitors local, state, and federal regulations and ensures compliance with accrediting and regulatory agencies’ standards and requirements.
• Monitors research and developments in the field of sepsis to identify best practice and assists with the development of educational resources and initiatives.
• Partners with clinicians to assure that current evidence is utilized in the treatment of sepsis.
• Assures policies, procedures, and practices are current and evidence-based relative to protocols and modifies as necessary.
• Participates in hospital committees, meetings, and shared governance focusing on sepsis; provides presentations and education as necessary to meet program goals.
• Develops action planning for improvement based on findings, data analytics, and cause analysis for the sepsis patient population.
• Initiate projects identify areas for improvement based on data analysis and collaborate with relevant stakeholders to implement projects. Regularly evaluate the effectiveness of quality improvement projects. Adjust strategies as need to achieve desired outcomes.
• Supports Resuscitation Committee / American Heart Association Get with the Guidelines/ Resuscitation.
• Review and abstract data from inpatient medical records to ensure accurate and complete information related to quality measures specified by CMS.
• Stay informed about CMS regulations, guidelines, and reporting requirements. Keep up to date with any changes or updates to the Inpatient Quality Reporting Program.
• Data validation auditing processes to ensure the accuracy and integrity of data being submitted to CMS
• Liaison with LHMC quality analytics and Vendor for data submission  

Required Qualifications

• Licensure: Current Massachusetts RN Licensure
• Education: Bachelor's degree in nursing (BSN)  
• Experience: 3-5 years of clinical nursing experience in an acute care hospital setting
• Knowledge, Skills, and Abilities
  • Sound facilitation skills.
  • Ability to understand process.
  • Ability to work within a team and independently.
  • Office 365 Word, PPT, and Excel proficiency
  • Superior interpersonal communication skills
  • Superior writing skills
  • Comfortable presenting to small and large groups 
  • Ability to organize, prioritize, and manage multiple responsibilities daily.
  • Ability to independently set priorities (self-starter)

Preferred Qualifications

• Education: Master's degree in nursing or other Healthcare related field
• Experience: Critical Care or Emergency Department experience.
• Certification: Certified Professional in Patient Safety (CPPS) or Certified Professional in Healthcare Quality (CPHQ)
• Knowledge, Skills, and Abilities
  • Knowledge of Lean Six Sigma or other project management / performance improvement principles.
  • Knowledge and experience with Joint Commission Standards.
  • Working knowledge of Microsoft Teams.

FLSA Status:

ExemptAs 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) and COVID-19 as a condition of employment. Learn more about this requirement.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