RN Disease Specific Certification Coordinator

The RN Disease Specific Certification Coordinator RN supports the achievement of the quality and patient safety priorities through quality assurance, quality management and quality improvement projects. This position facilitates data collection, analysis, reporting, presentation and corrective action determinations. This position also facilitates compliance with regulatory requirements related to organizational performance improvement. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

Manages the Stroke Program, Perinatal Care Program. and the Opioid Stewardship Program in collaboration with Risk.

Authorized to review, investigate on behalf of the risk management and compliance management programs. Abides by strict confidentiality related to findings and actions.

Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.

• Assists staff and management in the determination of reliable, valid and measurable quality and patient safety indicators.
• Identifies regulatory obligations for quality assurance (QA) and quality control (QC) activities, and assures that the organization is addressing regulatory requirements related to quality and patient safety
• Serves as the liaison between quality and patient safety activities and the associated data sources to assure the best data collected in the simplest, most efficient manner.
• Provides clinical and medical expertise to analysis of charts and indicator requirements.
• Abstracts data from medical records for quality measures and other projects assigned to the Quality Management Department; this includes concurrent and retrospective chart review.
• Performs data entry in appropriate databases, including QBRP and HQIC
• Organizes and facilitates multidisciplinary workgroups for each quality measure to improve outcomes.
• Provides back-up for other data analysts as needed (cross-trained).
• Assesses needs and provides education about quality measures to hospital employees and medical staff.
• Uses key tools to focus on process review rather than people review including process flow charting, priority matrices, Failure Mode and Effects Analysis (FMEA), run charts, Statistical Process Control (SPC) charts, and affinity diagrams.
• For concurrent abstraction & case reviews, may require:
  • Review of census and procedure schedules.
  • Rounding on nursing units.
  • Verification that appropriate documentation has been completed on current charting (includes communication with medical staff / hospital staff).
  • Review of Risk Management and Compliance Management
• Able to provide clinical expertise related to the nursing process.
• Maintains a presence that portrays professionalism and confidence to the customers served.
• Facilitates hospital accreditation & certification processes. Maintains a working knowledge of Federal, State and local laws and regulations, Corporate Compliance Program, Code of Ethics, Emergency Medical Treatment & Labor Act (EMTALA) and patient safety, as well as other policies and procedures and understands the role of other organizational leaders for each in order to ensure compliance.
• Abides by the Health Insurance Portability and Accountability Act (HIPAA) privacy and security regulations regarding all aspects of Protected Health Information (PHI).

• Develops and establishes objectives consistent with the American Heart and Stroke Association, The Joint Commission, and Hutchinson Regional Medical Center including Performance Improvement and Patient Safety programs.
• Coordinates the development, implementation, review, and revision of Stroke Program standards, policies, procedures, and protocols.
• Incorporates knowledge of AHA Guidelines as well as emerging science and evidence-based practice into Stroke program standards.
• Participates in Stroke Alerts when available to ensure protocols are followed.
• Rounds on admitted Stroke patients as needed to ensure protocols, and standards are met
• Assists in coordination of the Tele-stroke Program
• Leads and participates in performance improvement processes.
• Serves as the Get with the Guidelines database administrator.

• Partners with the Stroke program educator to ensure current best practices, clinical practice guidelines, and protocols are being followed.
• Participates in Kansas Stroke education/partners meetings.
• Provide real-time and just-in time education to staff when program requirements are at risk for not being met or not met.

• Remains current in research related to the stroke patient populations and stroke systems of care.
• Interprets and applies current research into clinical practice.
• Facilitates community Stroke education programs.
• Coordinates EMS Education in tandem with program educator.
• 8 hours of stroke education required for the Core Stroke Team

• Chairs relevant Stroke Program Committees related to quality improvement and regulatory adherence.
• Actively participates on internal, local, regional, and national advisory groups to work to advance the science of care for the person experiencing stroke

• Develops and establishes objectives consistent with The Joint Commission, and Hutchinson Regional Medical Center including Performance Improvement and Patient Safety programs.
• Coordinates the development, implementation, review, and revision of the Perinatal Care Program standards, policies, procedures, and protocols.
• Incorporates knowledge of The Joint Commission Standards as well as emerging science and evidence-based practice into the Perinatal Care standards.
• Leads and participates in performance improvement processes.

• Supports relevant Perinatal Care related committees in collaboration with Maternal-Child Health team members.

• Supports delivery of evidence-based acute stroke assessment and management.
• Provides expert nursing consultation and practice oversight.
• Manages critical pathway time frames. Evaluates patient outcomes and identifies and intervenes on variances.

• Knowledge of clinical process and medical documentation used in healthcare.
• Proficient in the use of Microsoft Word and Excel.
• Demonstrated ability to communicate effectively.
• Possess the ability to multi-task and initiate critical thinking skills when performing duties.

• Proficient in the use of Microsoft PowerPoint and excel or equivalent.
• Knowledge of regulatory compliance/accreditation standards (i.e. CMS; The Joint Commission).

• Associate's degree in Nursing (ADN).
• Three years of experience in a healthcare setting or equivalent experience.

• Bachelor’s degree in Nursing (BSN).
• Five years of experience in a healthcare setting or equivalent experience.

• Current RN license in the State of Kansas or compact license.
• NIHSS (National Institute of Health Stroke Scale) Certified (obtain within 1 year of start date)