In collaboration with the Trauma program leadership, the Trauma Performance Improvement Advisor is responsible for the coordination and facilitation of the Trauma Performance Improvement program, which encompasses all areas and disciplines of the hospital that participate in the care of admitted injured patients. Ensures that performance improvement projects support the Hackensack Meridian Health mission to improve the health of the community we serve through quality health care, education and research.
A day in the life of a Performance Improvement Advisor, Trauma at Hackensack Meridian Health includes:
Responsible for monitoring, maintaining and enhancing the quality of care delivered to trauma patients though the Trauma program Performance Improvement Process.
Utilizes the Trauma Registry to develop measures to provide a threshold for success and evaluation of processes.
Coordinates investigation, analysis, and responds to quality/patient safety issues, events, significant care issues or trends. Leads and/or facilitate root cause analysis, failure modes and effects analysis, and process improvement, working with multidisciplinary teams.
Demonstrates use of appropriate methodologies and relevant tools to opportunities to evidence rapid cycle improvement (i.e. PDSA, FMEA, reliability theory, bundle science, RCA, Process Flows, Affinity diagrams). Utilizes appropriate analytical tools and statistical process control to evaluate results. Assists teams with understanding and interpreting their data.
Ensures trend analysis is performed and appropriate response to unfavorable trends are developed and deployed.
Provides feedback and reevaluation of the process to staff and works with educators, department managers and other leaders to meet the goals of the department and the Trauma program.
Ensures that there is effective analysis of performance data with comparison over time and comparisons to internal and external benchmarks to identify improvement opportunities.
Documents performance improvement processes to determine success of actions and implementations and event resolution.
In conjunction with clinical leaders, performs focused studies on diagnosis, procedures and various performance measures based on pre-determined criteria.
Utilizes refined facilitation skills to ensure maximum participation of individuals and teams.
Uses CQI tools and principles in all team related work.
Ensures plans and designs are consistent with internal and external expectations for accreditation, regulatory compliance and public reporting.
Ensures that all meetings evolve to actionable work to reduce cycles of improvement.
Facilitates sharing and learning horizontally across the organization through participation in improvement day activities, presentations to teams, medical board committees, and assisting team members in knowledge synthesis.
Promotes the concept of cooperation and develops open lines of communication with department employees, patients, visitors, and other personnel within and outside the hospital.
Represents HUMC at local, regional and national meetings demonstrating and articulating the HUMC model for improvement and key results.
Acts as consultant and educator in program development and special projects as determined by the Trauma program leadership.
Works effectively with the medical staff to facilitate development and implementation of practice guidelines, resulting in the ability to profile physician activities, determine appropriate practice indicators in all clinical areas and produce effective outcomes.
Communicates problems or trends identified to appropriate committees, medical staff, administrative staff and/or management staff.
Works collaboratively with Risk Management in developing performance improvement activity.
Educates the appropriate personnel in the techniques of Performance Improvement through various modalities (didactic, Just in Time training).
Organizes and facilitates regularly scheduled training sessions with the managers, team leaders and staff as needed to educate and implement quality improvement principles and goals as a strategy.
Teaches the concepts of improvement ¿ Model for Improvement, Accelerating Improvement, Measurement for Improvement, Local Spread, Large-scale Spread and Sustaining Improvement at learning sessions and conference calls.
Provides coaching on improvement issues to participating teams at learning sessions, conference calls, list serve and emails necessary to achieve project goals.
Ensures design and improvement plans are fully compliance of JCAHO, NJDOH, American College of Surgeons, and Federal Standards. Assists with the design of materials to demonstrate compliance with standards.
Maintains current knowledge and expertise with external demands.
Represents the Medical Center with other quality improvement organizations, health agencies, groups, government agencies and third party payers at the local, regional and national level. Acts as a liaison to provider organizations to develop improvement strategies and determining strategies for success.
Ensures a systematic process for and supervises the investigation of incidents, sentinel events, near misses and ensures that a thorough root cause analysis is conducted when indicated. Ensures that there is an effective system in place for the identification, investigation and reporting of NJDOH required Patient Safety events. Monitors trends and identifies opportunities for improvement.
Adheres to the standards identified in the Medical Center's Organizational Competencies.
Maintains the strictest confidentiality of all patient information.
Maintains professional growth and development through seminars, workshops and professional facilitations to maintain and extend expertise.
Education, Knowledge, Skills and Abilities Required:
Bachelor of Science in Nursing or Health Care Administration.
Excellent written and oral communication skills.
Strong presentation and facilitation skills.
5 years of clinical experience in an acute care hospital.
Experience in the use of computer applications and software.
Education, Knowledge, Skills and Abilities Preferred:
Master Degree in Nursing, Business or Health Care Administration.
Understanding of JCAHO American College of Surgeons, and Regulatory Standards.
Recent 3-5 years experience in Quality or Performance Improvement measurement and statistics.
Trauma/ED/Critical Care experience.
Experience in data collection, data entry, data quality and integrity.
Licenses and Certifications Required:
NJ State Professional Registered Nurse License.
If you feel that the above description speaks directly to your strengths and capabilities, then please apply today!
Hackensack Meridian Health (HMH) is a Mandatory COVID-19 and Influenza Vaccination Facility
As a courtesy to assist you in your job search, we would like to send your resume to other areas of our Hackensack Meridian Health network who may have current openings that fit your skills and experience.