This position will lead the quality and safety initiatives for Memorial Home Health through collaboration with Memorial Health System Quality and Safety Department.  Coordinates and facilitates the quarterly MHSvc performance improvement, infection control and safety initiatives through data collection, analysis and reporting.  Monitors effectiveness of audit results in relation to CMS and Joint Commission regulations.  Develop and maintain operation dashboards for Home Health.  Responsible for research, knowledge of individual area work flows, department and system policies and environmental changes.  Serves as a resource person to Clinical Managers/Director.  

Education:

• Graduate from accredited school of nursing
• BSN preferred

Licensure/Certification/Registry:

• Registered nurse license in IL required.
• Lean Six Sigma Green Belt strongly preferred.
• Must have a valid IL driver’s license and must be deemed as an acceptable driver in accordance with the MHS Fleet Safety Policy (five year MVR will be required)

Experience:

• Minimum two years clinical experience required. Previous experience in quality, safety, and/or education/training preferred. 

Other Knowledge/Skills/Abilities:

• Accountability: Ability to hold people accountable to standards of performance or ensure compliance using the power of one’s position or force of personality appropriately and effectively, with the long-term good of the organization in mind.
• Achievement Orientation: A concern for surpassing standards of excellence. Standards may involve past performance (striving for improvement); objective measures (results orientationchallenging goals, or redefining the nature of the standards themselves (innovation).
• Analytical Thinking: Developing a deeper understanding of a situation, issue or problem by breaking it down or tracing its implications step-by-step. It includes organizing the parts of a situation, issue or problem systematically; making systematic comparisons of different feature or aspects; setting priorities on a rational basis; and identifying time sequences, casual relationships, or if-then relationships.
• Communication: Ability to use written and spoken communication in formal and informal situations to convey meaning, build shared understanding, and productively move agendas forward.
• Community Collaboration: Ability to align one’s own and the organization’s priorities with the needs and values of the community, including its cultural and ethnocentric values, and to move health forward in line with population-based wellness needs and national health agenda.
• Intellectual Curiosity: Underlying curiosity and desire to know more about things, people, and issues, including the desire for knowledge and staying current with health, organizational, industry, and professional trends and developments. It includes pressing for more precise information; resolving discrepancies by asking a series of questions; and scanning for potential opportunities or information that may be of future use, as well as staying current and seeking best practices for adoption.
• Initiative: Ability to identify a problem, obstacle or opportunity and then take action in light of identification to address current or future problems or opportunities. Initiative emphasizes proactively doing things and no simply thinking about future actions.
• Innovation: Ability to approach one’s work and the organization in new and breakthrough ways, including applying complex concepts, developing creative new solutions, or adapting previous solutions in promising ways.
• Performance Measurement: Ability to understand and use statistical and financial methods and metrics to set goals and measure clinical as well as organizational performance; commitment to and employment of evidence based techniques.
• Process and Quality Management: Ability to analyze and design or improve an organizational process, including incorporating the principles of high reliability, continuous quality improvement, and user-centered design.
• Professional and Social Responsibility: Demonstration of ethics, sound professional practices, social accountability, and community stewardship. Acting in ways that are consistent with one’s values and what one says is important.
• Self-Awareness: Ability to have an accurate view of one’s own strengths and development needs, including the impact that one has on others; willingness to address development needs through reflective, self-directed learning, and by trying new approaches.
• Self-Confidence: Possesses a belief in one’s own capability to accomplish their work. This includes confidence in one’s ability as expressed in increasingly challenging circumstances, and confidence in one’s decisions or opinions.

1. Coordinates, facilitates and ensures implementation of MHSvc Hospice quality management plan in conjunction with the for-profit entity of MHSvc and Memorial Health System.

2. Conducts educational needs assessments with MHSvc NFP management team and consults with other departments and/or affiliates to identify training needs.

3. Analyze, design, develop and implement educational activities to meet identified needs.

4. Maintain operational dashboard metrics for Hospice services and help analyze data to improve efficiencies.

5. Design and disseminates education related to products, processes and service lines to all related staff.

6. Communicates with ancillary departments to obtain appropriate materials needed to meet specified training needs.

7. Involved in new process design and policy revision in order to develop training and education accordingly.

8. Clear understanding of individual area work flows and the ability to cross train team members in all areas.

9. Maintains strict confidentiality concerning all correspondence and job related activities.

10. Oversight of quarterly quality improvement initiatives in regards to data collection and analysis.

11. Review mandatory CBL/Relias content for MHSvc appropriateness annually in conjunction with Memorial Health System Organization Learning and Development.

12. Participate in the development of annual measures of success consistent with Memorial Health System’s strategic Plan and Goals, and monitor the status of goal achievement.

13. Conduct risk assessments as required and create plan based on needs.

14. Identifies, obtains and ensures the proper utilization of resources associated with measuring and benchmarking data associated with QI initiatives. Coordinates medical chart audits and QI indicator results.  Uses data to identify trends/variances and analyzes results.

15. Assists with preparing for accreditation surveys, maintaining policies, procedures and processes to ensure compliance with regulations and accreditation surveys.

16. Prepares and submits reports for management meetings, Advisory board and other entities as requested.

17. Participates in the development and follow through of Joint Commission survey action plans for MHSvc.

18. In conjunction with MHSvc CI annually review and create addendum for to the MHS Quality Safety Management Plan for the key quality initiatives.

19. Participate in initiatives to improve Patient care and satisfaction metrics.

20. Performs other related work as required or requested