Manager - Quality Improvement and Education, Surgical Services Admin

Northside Hospital is award-winning, state-of-the-art, and continually growing. Constantly expanding the quality and reach of our care to our patients and communities creates even more opportunity for the best healthcare professionals in Atlanta and beyond. Discover all the possibilities of a career at Northside today.

PRIMARY FUNCTIONS AND RESPONSIBILITIES

Quality and Outcomes Management

1. Summarizes information received from departmental QI monitoring activities and communicates results to the Director of Surgical Services and the Medical Staff Office.

1. Coordinates the establishment and maintenance of standards of patient care and the mechanism to evaluate care within the department. Serves as a resource person to perioperative leaders in developing indicators and data sources for review and evaluation of practices and systems.

1. Assists in the formulation, implementation, review and revision of standards of care and standards of practice. Ensures surgical services compliance with patient care standards, hospital policies and procedures, recommendations from regulatory agencies, and the Joint Commission on the Accreditation of Healthcare Organizations (JACHO) Standard.

1. Monitors and coordinates surgical services policy development, evaluation, and revision process through delegation and collaboration with education coordinators.

1. Develops and maintains a data-tracking and management control system for the division, which includes problem identification, reporting, problem-focused studies, data analysis with problem summarization, mechanisms for feedback, and approaches toward resolution.

1. Participates with Risk Management in the investigator process for Incident Report follow-up. Identifies patterns and trends that could be inter-related with support systems, investigates problems, irregularities and policy variations, and makes recommendations for follow-up.

1. Coordinates, provides resource assistance, and evaluates the effectiveness of the QI program. Reviews perioperative unit reports and makes recommendations for corrective or follow-up action. Evaluates the effectiveness of problem-solving techniques and recommends new approaches when indicated.

1. Participates in the development, maintenance, review and evaluation of patient charts and other tools used for care delivery documentation.

1. Serves as a resource and consultant to surgical services leadership related to quality, safety, care management, education and special projects.

Quality and Outcomes Management (cont)

1. Initiates, assists in the design, and coordinates special projects and teams or studies related QI training, care management, customer satisfaction and others, based on identified opportunities.

1. Prepares reports for the NSH Operational value Improvement Committee.

1. Participates in the development, maintenance, review, and evaluation of perioperative QI reports.

1. Prepares and presents reports for Surgery Exec/Surgery QI/GYN QI for approval, endorsement, and/of further recommendations and follow-up.

1. Collaborates with the Director of Surgical Services, Managers and Coordinators to prepare the annual report, annual appraisal, quarterly compliance report, Value Improvement Plan and periodic updates as needed.

1. Generates reports as needed and shares information as appropriate

1. Develops, implements, and evaluates the Surgical Services Education Program facilitating perioperative clinical orientation and competency assessment.

1. Identifies educational and training needs of all perioperative units, staff, or individual(s) impacting assigned functions and plans with the Perioperative Education Coordinator(s) and other appropriate staff members of the implementation of training needs.

1. Participates in activities designed to continue individual professional growth and advancement of the goals of the nursing profession.

1. Conducts staff and management education and in-service activities related to quality, safety, care management and customer satisfaction. Coordinates the development and implementation of the department orientation process.

1. Collaborates with clinical faculty in providing and coordinating learning experiences for nursing and surgical technician students.

1. Coordinates education for surgical service teams regarding clinical pathways.

1. Maintains accountability for the achievement of capital and operating budget objectives within area of responsibility.

1. Participates in cost containment activities.

1. Demonstrates sound judgment and critical thinking in resource utilization.

1. Evaluates equipment and supplies for appropriate safety and cost effectiveness on a daily basis. Analyzes product and service offerings from manufacturers, group purchasing organizations, and distributors. Identifies and submits alternative contract proposal recommendations to Director for consideration.

1. Evaluates products for financial effectiveness and collaborates with appropriate clinical experts regarding clinical efficacy.

Human Resources

1. Recruits, hires, orients, and evaluates performance of Perioperative Education Coordinators and other assigned personnel to assure the surgical services quality and education positions are staffed with individuals who reflect behavior and performance consistent with the hospital's Mission and Values statement. Has authority to hire, terminate and/or take other disciplinary action as may be deemed appropriate and is in accordance with hospital policy.

1. Communicates regularly with departmental staff to disseminate information, which will assist, in the safe and effective performance of their jobs and to create an understanding of hospital-wide performance and direction.

1. Demonstrates effective communications with staff members, peers, surgeons, and anesthesia personnel contributing to the productivity of the work place.

1. Maintains continuous feedback processes between members of the Surgical Services Management Team.

1. Resolves conflicts and other issues exercising professional judgment in the application of policies and procedures.

1. Establishes collegial relationships with other surgical service leaders and hospital professionals to collaborate and coordinate quality management and educational activities.

1. Integrates departmental services with the hospital's primary functions.

1. Coordinates and integrates services within department and with other departments.

1. Develops and implements policies and procedures to guide and support the provisions of services.

1. Recommends a sufficient number of qualifies and competent persons to provide care.

1. Determines the qualifications and competence of department personnel who provide patient care services and who are not licensed independent practitioners.

1. Continuously assesses and improves departmental performance.

1. Maintains appropriate quality control programs.

1. Provides for orientation, in-service training, and continuing education of all persons in the department.

1. Recommends space and other resources needed by the department.

1. Participates in selecting outside sources for needed services.

1. Contributes to the development of the philosophy, goals and objectives, and policies and procedures, which meet patient/customer, departmental, and hospital needs.

1. Actively participates in the strategic planning process for surgical services obtaining and interpreting data from Decision Support, Human Resources and other departments as required.

1. Demonstrates effective role modeling and mentor-ship to surgical service personnel for perioperative clinical and administrative initiatives.

1. Serves as a departmental or institutional representative and consultant to outside agencies and organizations.

1. Evaluates research findings related to perioperative nursing and participates in active research initiatives as appropriate.

1. Demonstrates service excellence behaviors routinely in encounters with all customers, i.e., co-workers, patients, visitors, physicians, auxilians, etc.

1. Practices proper safety techniques in accordance with hospital and departmental policies and procedures. Immediately reports any mechanical or electrical equipment malfunctions, unsafe conditions, or employee/patient/visitor injury-accident to Director.

1. Performs other duties as assigned.

REQUIRED

• Graduate of an accredited school of Nursing with a minimum of five (5) years perioperative nursing experience in Nursing, with at least two (2) years supervisory, managerial, or responsible nursing experience; or an equivalent combination of education, training, and experience.

• Excellent analytical and interpersonal skills.

• Excellent written and oral communication skills.

PREFERRED

• Bachelor's Degree in Nursing or Health Care Administration from an accredited college or university.

• Experience in all surgical nursing specialties

• Quality Improvement certification.

• Experience as a perioperative nursing educator.