Job Description

Essential Functions:

Essential functions are those tasks, duties and responsibilities that are performed with or without reasonable accommodation.

• Works in conjunction with UHSH Chief Nursing Officer/Vice President Patient Care Services or CMH Vice President of Clinical Services, Patient Care Services Leadership, and Quality Management, as well as UHS system members. Reviews regulatory requirements from Joint Commission/ACHC, Department of Health, and CMS as they apply to Patient Care Services (PCS).

• At UHSH, Manages the Assistant Coordinator of Nursing Quality and Safety.

• At CMH, Manages MDS assessment entries and submissions.

• At CMH, Supports Swing Bed program operations and regulatory compliance.

• Coordinates with Quality Management to identify quality issues.

• Participates in multiple interdisciplinary committees which focus on quality, fall prevention, and safe patient handling. Analyzes data and reports from these committees to identify areas of improvement for Patient Care Services.

• Works with Nursing Leadership to implement plans which will facilitate improvement in areas identified.

• Acts as a resource and consultant to nurse managers, nursing staff, and nursing education staff.

• Participates in unit specific quality improvement plans using the PDSA model and implements rapid action plans as needed and supports sustainability for action plans.

• Participates in and supports Nursing councils, committees, and leadership meetings by providing performance improvement data, updates from special projects, updates related to regulatory issues, nursing practice issues and other meetings that impact the falls prevention program.

• Site coordinator for NDNQI program. Reviews data from these reports to make recommendations to entity's Nursing Leadership (i.e. Chief Nursing Officer, VP, DONs, SLMs, and/or Assistant Coordinator of Nursing Safety and Quality) on nurse‐sensitive quality issues.

• Acts as a resource and consultant to UHSH Nursing Education and Professional Practice or CMH Training and Development related to educational requirements, policy and procedure updates, and form changes that will require education for all nursing staff.

Non‐Essential Functions:
Duties the employee may perform that are not essential as defined in the job description.

• Will perform additional responsibilities, as requested

Education/Experience

• Minimum Required:
  • Bachelor's Degree in Nursing or Healthcare Administration (For CMH, must at minimum be currently enrolled in Bachelor's program and complete within 2 years of hire)
  • Three (3) years of experience in a hospital setting to include background in clinical operations, quality improvement, regulatory compliance, and patient safety
  • Lean Expert required within 1 year
• Preferred:
  • Lean Expert
  • For CMH, MDS experience in LTC or Swing Bed setting

License/Certification

• Minimum Required:
  • Current New York State license as a Registered Nurse
  • CPR within 3 months of hire
• Preferred:
  • Professional certification in a related specialty

Work Environment

• Work is performed in an offices or meeting rooms which require working in proximity to other employees and patients. Rooms are air conditioned and heated. Sitting for long periods with some travel to other UHS System facilities. PPE (Eyewear, Masks, Face shields, Shoe covers, and Gloves) as required by UHS Hospitals Infection Control policies.

Age of Patients Served

• Not Applicable

HIPAA Roles‐Based Access to Patient Information

• All ‐ Access to patient information, including restricted information ‐ Level 4

Staff Supervised

• At UHSH, 1 ‐ Assistant Coordinator of Nursing Safety and Quality
• At CMH, none

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