The Senior Improvement Nurse serves as a strategic partner, responsible for facilitating on behalf of the Quality Institute, the assigned facility and/or the assigned market improvement initiatives that target one or more system priorities including the development of the scope, design, implementation, control, and validation of the initiatives outcome results. The Senior Improvement RN may be responsible for developing and leading improvement activities at the entity and system level in the following areas:

• Performance Improvement & Change Management
• Develops and leads performance improvement activities as defined by organizational priorities. Provides direct input into Zero Harm initiatives with facility and market leadership teams. Plans development and partners with facility Process Improvement teams to implement action plans to achieve specific target outcomes successfully. Works with diverse interdisciplinary teams composed of subject matter experts across the UH System. Evaluates “Best Practice” benchmarks and best practice model examples, recommending strategic implementation at the entity. Analyzes data to measure current process performance to best practices to identify, quantify and prioritize PI opportunities and efforts. Evaluate waste versus value-added activities based on Voice of the Customer (VOC) service needs and expectations. Review care of patients (concurrent and retrospective) to assess for complications of care and adherence to published practice standards. Liaison with the physicians, nurses and ancillary staff regarding Quality and Patient Safety, and other quality/risk initiatives, including publically reported indicators. Attends departmental meetings, as assigned, to serve as Quality Institute representative and subject matter expert. Develops, as requested, quality & safety presentations as assigned for presentation to a variety of audiences. Performs tracer activity to assure compliance with all regulatory standards. Serves as preceptor, coach and mentor to staff regarding performance improvement and other quality initiatives. Communicates opportunities for improvement to unit/departmental leadership as identified. Facilitates communication with leadership on organizational opportunities for improvement at unit or department level.
• Clinical Risk
• Leads an effective effort within the organization to identify and mitigate clinical risk and reduce patient harm. Leads, in conjunction with Manager and Quality Institute Leadership, to develop priorities as it impacts Clinical Risk Management. Maintains a continuous process for identification of adverse outcomes and complications. Coordinates with Law Department to assure Risk Management issues are addressed in a timely and appropriate manner. Leads Performance Improvement activity related improvement of patient safety and reduction of adverse events. Data management including collection, entry, trending and analysis to support performance improvement. Ability to summarize and analyze clinical and operational data, develop summary reports, charts, and graphs, trend outcomes, and identifies opportunities for improvement from the data analyses.
• Patient Safety
• Collaborates with Manager and Quality Institute Leadership to develop annual priorities as it impacts Patient Safety. Maintain an effective Patient Safety Program for this facility based on the current priorities. Leads Performance Improvement activity related initiatives to positively impact Patient Safety and Reduction of Adverse Events. Proactively identifies best practices and process redesign to improve patient safety.
• Accreditation & Regulatory Compliance
• Coordinates organization wide continuous accreditation readiness and continuous regulatory compliance, including a proactive tracer program. Creates and maintains data collection to support and drive accreditation functions. Organizes and actively participates in process improvement initiatives to improve compliance with accreditation standards. Under direction of manager / administrator disseminates data and feedback on compliance with accreditation standards to all stakeholders. Participates with UH Accreditation team to enhance monitoring, promote needed practice changes and improve compliance system wide. Is actively engaged in review of updates to accreditation standards (DNV, CMS, TJC, & Specialty) and timely communication of changes to involved stakeholders. Shares regulatory (DNV/TJC/ODH/CMS) communications. Provides feedback as required to DNV/TJC via secure site.
• Infection Prevention Nurse
• Perform infection surveillance, analysis, interpretation and reporting of hospital acquired infections (HAIs). Act as a resource for Employee Health program working collaboratively to review and investigate potential employee Infection Control Issues and maintain compliance with federal, state and city health codes, regulations and agencies including the Ohio Department of Health, OSHA and CMS. Monitor and analyze patient care practices. Actively participate in infection reduction initiatives in order to prevent and reduce HAIs. Conduct education and ongoing in-service programs for multi-disciplinary health care teams. Assure compliance with policy and procedure to ensure standards that meet DNV, TJC, OSHA, CMS, ODH, CDC standards, recommendations and requirements. Maintain knowledge of current guidelines, regulations and best practices relating to infection prevention. In collaboration with the hospital’s Infectious Disease physician, or IC Medical Director oversees and coordinates infection control policies, hospital Infection Control Committee, Infection Control Risk Assessment and Infection Control Plan, and Infection Control data submission (e.g. NHSN for CMS compliance and communicable disease reporting etc.). Active membership in APIC

• Performs other duties as assigned.
• Complies with all policies and standards.
• For specific duties and responsibilities, refer to documentation provided by the department during orientation.
• Must abide by all requirements to safely and securely maintain Protected Health Information (PHI) for our patients. Annual training, the UH Code of Conduct and UH policies and procedures are in place to address appropriate use of PHI in the workplace.