Quality
1.0 FTE, 8 Hour Day Shift
At Stanford Children’s Health, we know world-renowned care begins with world-class caring. That’s why we combine advanced technologies and breakthrough discoveries with family-centered care. It’s why we provide our caregivers with continuing education and state-of-the-art facilities, like the newly remodeled Lucile Packard Children’s Hospital Stanford. And it’s why we need caring, committed people on our team – like you. Join us on our mission to heal humanity, one child and family at a time.
Job Summary
This paragraph summarizes the general nature, level and purpose of the job.
In conjunction with the Surgeon-in-Chief/Medical Director Children’s Surgery (MDCS) and the Children’s Surgery Program Manager (CSPM), coordinates performance improvement (QI) initiatives to monitor and improve current processes and outcomes for surgical patients and promote safe practice. Represents The American College of Surgeons (ACS) Children’s Surgery Verification (CSV) Program in joint quality improvement (QI) initiatives by gaining stakeholders from other areas of the hospital and community and coordinating new initiatives as recommended by the ACS Resource for Optimal Care of the Surgical Patient. Serves as a facilitator and change agent. Responsible for assessing the adherence to current performance improvement indicators while assisting to develop and monitoring of new quality improvement measures. Reviews and assures completion of abstracted data from the medical record, including care provided by Perioperative Services and hospital units from admission through 30 days postop. Responsible for monitoring compliance with established standards as set forth by the established policies and procedures of the Surgery Clinical program as well as such regulatory agencies as the American College of Surgeons (ACS) Children’s Surgery Program. Participates in the monitoring of performance standards that keep the Surgery Program in compliance with the ACS Children’s Surgery Program. Monitors the accuracy of data in the surgery registry through established criteria participates in surgery education and clinical activities as needed.
Essential Functions
The essential functions listed are typical examples of work performed by positions in this job classification. They are not designed to contain or be interpreted as a comprehensive inventory of all duties, tasks, and responsibilities. Employees may also perform other duties as assigned.
Employees must abide by all Joint Commission Requirements including but not limited to sensitivity to cultural diversity, patient care, patient rights and ethical treatment, safety and security of physical environments, emergency management, teamwork, respect for others, participation in ongoing education and training, communication and adherence to safety and quality programs, sustaining compliance with National Patient Safety Goals, and licensure and health screenings.
Must perform all duties and responsibilities in accordance with the hospital’s policies and procedures, including its Service Standards and its Code of Conduct.
Partners and collaborates with the Surgeon-in-Chief/Medical Director Children’s Surgery (MDCS) and the Children’s Surgery Program Manager (CSPM) and coordinates performance improvement (QI) initiatives to monitor and improve current processes and outcomes for surgical patients and promote safe practice. Coordinates, evaluates, and facilitates the implementation and monitoring of quality standards across the continuum of care including the planning and implementation of clinical protocols and proactive management guidelines, monitoring care of in-hospital patients, and serving as a resource for surgical quality improvement.
Represents The American College of Surgeons (ACS) Children’s Surgery Verification (CSV) Program in joint quality improvement (QI) initiatives by gaining stakeholders from other areas of the hospital and community and coordinating new initiatives as recommended by the ACS Resource for Optimal Care of the Surgical Patient.
Serves as a Subject Matter Expert (SME) for level chart reviews, validates and monitors compliance with established standards of care as defined by the ACS criteria for Level 1 Children’s Surgery Center designation. Presents all identified safety events and/or opportunities for improvement to the CSMD and the CSPM for review and direction.
Coordinates follow up with Transport, ED, Perioperative Services, Critical Care Units, postoperative care units on issues of non-compliance with the standards of care and assures loop closures on those QI issues.
Identifies Quality Improvement opportunities for the CSV Program and Children’s Surgery Quality, Safety and Value Program (CSqsvP). Bases initiatives on evidence-based processes when possible and works with CSPM and cpmV Quality Advisor to create a plan to implement all required monitoring.
Provides analytical and programmatic support to ongoing QI/PI surgical program projects and initiatives. Gathers intra-facility support as needed to develop each QI measure. Provides data mining and quality assurance of assigned database, internal and external data sources.
Monitors ASC Children’s Surgery Safety Events (CSSE, A1 events) and analyzes the data. Creates reports as indicated and provides feedback to individuals when care falls outside of expected standard.
Reviews medical records/reports to collect clinical data; validates data through comparison. Participates in and contributes to opportunities to develop action plans and implement best practices to ensure the highest quality data for the safest outcomes in the organization.
Collaborates with the quality team to oversee the quality program and provision of care to surgical patients; ensures that the quality of service provided complies with regulatory requirements and hospital policy.
Collects and presents responses for QI opportunities to the CSV PIPS Committee (SPQC) and demonstrates loop closure for individual and system QI initiatives. Facilitates system changes based on findings.
Investigates reported quality and safety concerns and works with hospital departments to determine course of action to loop closure.
Collaborates with Surgeon in Chief/MDCS and the CSPM to meet needs of the CSV Program.
Participates in individual, staff, committee, divisional, and/or organizational meetings as needed.
Participates in and attends continuing education sessions to maintain knowledge of current trends and technology of field.
Minimum Qualifications
Any combination of education and experience that would likely provide the required knowledge, skills and abilities as well as possession of any required licenses or certifications is qualifying.
Education: Bachelor of Science Degree in Nursing required.
Experience: 5 years pediatric inpatient nursing, preferably with pediatric surgical patient population. PICU experience preferred.
License/Certification: Current CA RN license required.
Knowledge, Skills, & Abilities
These are the observable and measurable attributes and skills required to perform successfully the essential functions of the job and are generally demonstrated through qualifying experience, education, or licensure/certification.
Ability to communicate effectively, both orally and in writing.
Ability to identify problems and implement solutions for operational and organizational functions.
Interpersonal skills necessary to work with multi-disciplinary team to design and maintain excellence in the delivery of surgical care.
Professional knowledge of nursing theory and practice.
Technical and professional knowledge unique to the business and/or clinical operations of the designated services (Nursing, Financial, Human Resource, Information Systems, Risk, Governance, Regulations, Planning and Marketing).
Ability to promote a spirit of inquiry and practice based on evidence by using research based knowledge or research utilization methods to identify and implement innovations in patient care and/or participating in research, clinical investigatory or quality projects.
Physical Requirements and Working Conditions
The Physical Requirements and Working Conditions in which the job is typically performed are available from the Occupational Health Department. Reasonable accommodations will be made to enable individuals with disabilities to perform the essential functions of the job.
Pay Range
Compensation is based on the level and requirements of the role.
Salary within our ranges may also be determined by your education, experience, knowledge, skills, location, and abilities, as required by the role, as well as internal equity and alignment with market data.
Typically, new team members join at the minimum to mid salary range.
Minimum to Midpoint Range (1.0 FTE): $149,552.00 to $187,574.40
Equal Opportunity Employer
Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or gender identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability, or the perception of any of the above. People of all genders, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply. Qualified applicants with criminal convictions will be considered after an individualized assessment of the conviction and the job requirements, and where applicable, in compliance with the San Francisco Fair Chance Ordinance. #LI-GP1
Lucile Packard Children’s Hospital Stanford strongly values diversity and is committed to equal opportunity and non-discrimination in all of its policies and practices, including the area of employment. Accordingly, LPCH does not discriminate against any person on the basis of race, color, sex, sexual orientation or identity, religion, age, national or ethnic origin, political beliefs, marital status, medical condition, genetic information, veteran status, or disability. Women and men, members of all racial and ethnic groups, people with disabilities, and veterans are encouraged to apply.
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