Specialist, Quality Safety

MERCYONE (Des Moines, Genesis, Mason City & Waterloo)
POSITION DESCRIPTION
Job Code:
Title: Specialist Quality and Safety
Date: October 2, 2023 Department: Quality
FLSA: Exempt Reports To: Manager of Quality and Safety
Grade:
Approved By: Human Resources
POSITION PURPOSE
The purpose of the Specialist of Quality and Safety is to assist and support the manager in quality and safety strategies, plans, and regulatory requirements that improve outcomes and reduce harm to patients. The specialist works closely with ministry colleagues, providers, and leaders in implementing, monitoring, and evaluating quality and safety programs, structures and requirements that culminate in high reliability.
The specialist, under the direction of the manager, assists in achieving excellence in quality and safety work related to patient outcomes (process and outcome measures), performance improvement strategies and methodologies, culture of safety (TogetherSafe) initiatives, and patient safety organization (PSO) collaboration with risk management that ensures high quality and safe care.
The specialist reports directly to the local manager of quality and safety.
ESSENTIAL FUNCTIONS
1. Knows, understands, incorporates, and demonstrates the MercyOne (Trinity Health) Mission, Vision, Core Values, Actions and Promise in behaviors, practices, and decisions.
2. 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.
3. 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.
4. Identifies problem areas in need of focused attention and supports the manager to implement actions to drive improved outcomes.
5. 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.
6. Promotes continuous improvement toward achieving excellent outcomes and recognition in regards to outside "rating" organizations, including (not all inclusive) CMS, Leapfrog, Healthgrades, Blue Distinction etc.
7. Collaborates with hospital executive leadership, medical staff, and leaders in meeting/exceeding standards of excellence and achieving national designations, certifications, and awards.
8. Collaborates with colleagues in areas of accreditation, risk management, patient experience, and performance excellence to provide identified and needed support for improvement.
9. Assists with implementation of quality excellence systems that integrate LEAN and other methodologies as appropriate to create a data-driven quality improvement programming.
10. Provides appropriate support, and/or consultative services (project design, selection of data required, development of documentation tools, etc.) to quality improvement teams.
11. Works closely with colleagues in improving the organization's culture of safety - including the concept of a "Just Culture" and "TogetherSafe".
12. 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.
13. 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.
14. Promotes an environment of shared leadership, decision-making and accountability.
15. 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.
16. Supports organizational evidence-based practice, innovation and research.
17. Assists the manager in the clinical contracting process, consistent with legal and regulatory requirements.
18. Contributes to the quality process in evaluating medical staff performance, inclusive of the focused and ongoing professional practice evaluation review process.
19. Maintain awareness of and respond to issues in areas including the following:
o Ethnic, cultural and diversity changes in the population
o Political and social influences
o Financial and economic issues
o The aging of society
o Ethical issues related to healthcare
20. Perform other duties consistent with the purpose of the job as directed.
SKILLS AND ABILITIES REQUIRED:
1. An understanding of the health care environment and all applicable laws and regulations.
2. Knowledge of high reliability organizations, quality excellence, shared governance, and continuous improvement.
3. The ability to synthesize and interpret clinical, quality, and financial data.
4. Proven time management skills with the ability to prioritize and organize work/projects in a fast-paced working environment so that all tasks are completed on time and accurately.
5. Keeps current in area of expertise and assure that standards and practices reflect best practice within area of expertise.
6. Maintains a professional, collaborative work environment so as to foster a positive public image for MercyOne.
7. Possesses a personal presence that is characterized by a sense of honesty, integrity, and caring with the ability to inspire and motivate others to promote the philosophy, mission, vision, goals, and values of MercyOne and Trinity Health.
8. Provides a high level of customer responsiveness and serves as a role model to encourage a commitment to customer service. A strong service orientation is required.
9. Excellent written and verbal communication skills with the ability to relate to people across all levels & diverse backgrounds; ability to handle interactions with discretion, tact & courtesy.
10. Strong relationship builder, consultant and demonstrate the ability to deal successfully with inherent ambiguities and complexities.
11. Skilled in the areas of consensus and team building, colleague engagement, delegation, conflict management, etc.
12. Flexible and demonstrates a great tolerance for change with ability to manage self and others through change.
13. High aptitude for learning quickly, acting maturely and ethically.
14. Ability to think creatively and analytically.
15. Ability to demonstrate initiative.
16. High degree of professionalism.
17. Ability to handle confidential information in a sensitive manner.
18. Demonstrates leadership skills and ability to implement processes and procedures.
LEADERSHIP COMPETENCIES
As a MercyOne Trinity Health Leader, the incumbent is expected to demonstrate leadership traits which support our Mission Statement and Core Values as identified below:
Mission Statement: We, MercyOne Trinity Health, serve together in the spirit of the Gospel as a compassionate and transforming healing presence within our communities.
Core Values:
• Reverence: We honor the sacredness and dignity of every person.
• Commitment to Those Experiencing Poverty: We stand with and serve those who are experiencing poverty, especially those most vulnerable.
• Safety: We embrace a culture that prevents harm and nurtures a healing, safe environment for all.
• Justice: We foster right relationships to promote the common good, including sustainability of Earth.
• Stewardship: We honor our heritage and hold ourselves accountable for the human, financial and natural resources entrusted to our care.
• Integrity: We are faithful to those we say we are.
MINIMUM QUALIFICATIONS
1. Education:
o Bachelor's degree in nursing, health administration or related field required.
o Iowa licensure as a Registered Nurse.
2. Experience:
A. Requires a minimum of three (3) years in hospital setting.
3. Special Skills, Competencies, and Aptitudes:
A. Member of a professional healthcare organization.
B. Demonstrated expertise in the use of performance improvement methodology/tools.
C. 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.
PHYSICAL AND MENTAL REQUIREMENTS AND WORKING CONDITIONS
1. Normal work environment where there are relatively few physical discomforts due to dust, dirt and noise.
2. In an eight-hour day, must be able to sit for 3 ½ hours, stand for 3 ½ hours, and walk for 1 hour.
3. Must be able to occasionally (6-10% of work time) lift/carry objects weighing approximately 35 lbs.
4. Occasional (10% of work time) squatting, crawling, crouching, kneeling, balancing, pushing, pulling, frequent bending/stooping, and reaching above shoulder level.
5. Must frequently (21-50% of work time) maintain high level of concentration with many interruptions and attain desired deadlines.
6. Requires use of hands for actions such as typing, simple grasping, fine manipulation, and repetitive actions.
7. Requires the ability to frequently respond to multiple demands and priorities.
8. Has potential for exposure to infectious diseases, hazardous waste and chemicals.
9. Requires visual acuity, the ability to speak and the ability to hear speech.
10. Must be able to travel to other MercyOne owned and/or affiliated sites, training seminars, etc.
11. Must adhere to applicable organizational requirements on an annual basis for Employee Health Directives.
12. Must possess the ability to comply with Trinity Health policies and procedures.
DISCLAIMER STATEMENTS
The intent of this job description is to provide a representative summary of principle responsibilities and duties performed. It is not intended to be an exhaustive list of all the job-related responsibilities and duties that incumbents may perform. Incumbents will be required to perform any other job related duties required by their supervisor. An associate may be called upon to perform physical actions not specifically identified in this job description. All responsibilities and duties listed in this description are essential functions. All requirements are subject to possible modification to reasonably accommodate individuals with disabilities.
Requirements are representative of minimum levels of knowledge, skills and/or abilities. To perform this job, incumbents will possess the abilities or aptitudes to perform each duty proficiently. Additional unit and/or age-specific knowledge, skills or abilities will need to be demonstrated based on specific competencies maintained in each department.
This organization is an equal opportunity employer and does not discriminate against individuals on the basis of race, color, age, sex, national origin, creed, or qualified individuals with disabilities.
This document does not create an employment contract, implied or otherwise, other than an "at will" employment relationship.