Unit SQS Special Delivery Unit
Local program leader for patient safety and quality improvement initiatives that improve patient outcomes within a defined patient care area (microsystem). Utilizes CHOP improvement framework, sustains and spreads improvements. Effectively partners with nursing and medical leadership to determine improvement priorities that are in alignment with organizational goals. Develops strong working teams to make improvements. Inspires members of the clinical area to fully engage in improvements that achieve high outcomes and works to ensure there are zero events of preventable harm. Develops and advances own expertise related to quality improvement, change management, high reliability, influence, and project management. Fully masters the organizational leadership competencies.
Develops, implements, evaluates, and sustains an effective microsystem based safety and quality program:
- In collaboration with the NM and medical director, develops and communicates safety/quality goals and metrics relevant to the clinical area. Works with other leaders to prioritize and resource improvement work. Coaches on improvement and ensures initiatives are aligned with organizational mission, vision, values, and goals. Encourages alignment of initiatives with three patient/family centered values (Healthcare Performance Improvement consultants, 2008):
- Do not harm me
- Heal me
- Be nice to me
- Fosters a fair and just culture of patient/employee safety within the microsystem.
- Coaches and mentors on safety behaviors for error prevention.
- Applies high reliability principles (sensitivity to operations, reluctance to simplify, preoccupation with failure, deference to expertise, and resilience) to safety and quality issues whenever possible.
- Integrates improvement initiatives to achieve overall patient outcomes i.e. assures clinical improvement initiatives also promote excellent patient/family experience.
- Orients, develops and mentors lead nurses of the working teams that are linked within the safety program.
- Partners with nurse manager or clinical supervisor when members of initiative teams are challenged in meeting their responsibilities.
- Applies the CHOP Improvement framework to all improvement work.
- Assures data-based decision making for all initiatives.
- Applies project planning techniques for all initiatives.
- Provides effective, timely communication regarding safety and quality initiatives and outcomes, including visual displays of data to inform all microsystem staff of the status of improvement efforts.
Coordinates action – oriented, outcomes – oriented, microsystem improvement initiatives:
- Ensures all initiatives have specific project timelines and that the work stays on the expected track.
- Actively utilizes project management skills.
- Whenever possible, scopes the work to ensure that achievements are possible i.e. break large goals into sub-projects that lead to the systematic achievement of the goal.
- Advises and/or seeks resources to determine effective measures and metrics for improvement initiatives; assures appropriate data support is in place.
Serves as an effective change agent:
- Provides coaching and consultation to staff from all disciplines in making behavioral changes.
- Partners with shared governance and nursing/physician leadership to influence practice changes.
- Develops plan to assure practice change has occurred and is sustained.
- Role models self confidence in making necessary changes.
- Reevaluates improvement plans and make adaptations when anticipated outcomes are not achieved.
- Promotes the notion of adapt, adopt, and/or abandon so that initiatives do not become ‘stuck” at mediocre results.
Fluent and facile in improvement methodology and tools; serves as a resource to improvement teams.
- Assures sustainment plan is considered and incorporated in the beginning of each project.
- Applies force field analysis prior to the initiation of projects to assure it is achievable and barriers are addressed prior to initiation.
Investigates microsystem good catch (near-miss) and harmful events.
- Conducts ACAs when needed.
- Partners with multidisciplinary team as needed during the investigation process.
- Enters, retrieves, and trends data regarding patient care events.
- Assures timely, accurate completion of bedside reviews for events of Healthcare Acquired Conditions; follows standard format.
- Focuses on systems issues during the investigation process.
Supports microsystem based structures and processes related to safety and quality initiatives:
- Develops agendas for microsystem forums i.e. QI meetings and/or Unit Leadership partner meetings.
- Effectively facilitates meetings.
- Documents meeting notes.
- Identifies microsystem safety/quality trends.
- Identifies the need for training when applicable.
- Compiles annual report of microsystem initiatives and achievements.
Required Education: Bachelor’s degree in a health care field. According to the CMS (Centers for Medicaid and Medicare Services) a copy of diploma or transcript is required as proof of academic achievement for all non-laboratory personnel performing non-waived POC testing
Required Experience: Minimum of two (2) years of work experience in a complex health care setting
-RN, EMT, CRT, or Pharmacy Licensure in the Commonwealth of Pennsylvania within nine (9) months of placement into position
-Certified Professional in Healthcare Quality (CPHQ) within two (2) years of placement into position