POSITION SUMMARY
Under the direction and supervision of the Director of Quality, the Harms Prevention Coordinator RN is responsible for reducing the number of preventable and other harms attributed to the facility. This is completed through a systematic process of prospective chart review, direct collaboration with the patient care team, and the facilitation of performance improvement initiatives identified as the best practices for harm prevention.
Responsibilities shall be discharged in such a manner as to support the goals and objectives of the Medical Center’s quality improvement and patient safety program and in keeping with Mission, Philosophy, and values of the organization.
PRIMARY (ESSENTIAL) DUTIES
1. Promote Quality and Patient Safety
a. Retrospective review of assigned harms to identify trends and opportunities for improvement.
b. Concurrent review of patients with sepsis to identify potential gaps in care and address with the providers, and staff prior to discharge.
c. Maintain a working knowledge of the harms categories through researching the CMS and other source specifications.
d. Research of evidence-based practices and presentation to PI Teams for review and consideration.
e. In conjunction with peers and the Infection Preventionist will provide cross coverage to ensure that Interdisciplinary Rounds and Unit Based Rounds are sufficiently covered daily to ensure early identification
of potential opportunities for preventing harms.
f. Analyze and collate data for review by the PSCQ and/or Clinical Investigation Team.
g. Use of the PI toolkit to facilitate and participate on PI Teams to improve processes related to harms reduction strategies including accurate agendas, minutes, and follow up.
h. Review of processes and/or documentation to ensure adherence to quality & safety regulations, standards, and policies and procedures.
i. Evaluate risk of harm for patients and communicate to the care team to ensure early and proper implementation of appropriate interventions.
j. Work with the Director of Quality and the Data Analyst Specialist to ensure data presentation accurately displays the outcomes and process measures to drive change.
k. Conduct a Root Cause Analysis in conjunction with the department directors through record review, and staff interviews on each attributed Harm and share with the CIT and/or applicable PI Team.
2. Conduct CMS and TJC Core measures abstraction or participate in the Inter-Rater Reliability process for these same measures as required.
a. Maintain knowledge of the CMS and TJC requirements for reportable measures.
b. Perform data entry that includes abstracting data from the EMR to maintain assigned database for required reporting.
c. Share data with appropriate personnel and committees in timely manner.
d. Actively participate in evaluating medical center performance with these activities and recommend and participate in developing changes to improve identified processes to improve patient care and safety.
General:
1. Protect confidentiality of all activities and data.
2. Keep department Director informed of all activities, concerns, and improvement opportunities as necessary.
3. Maintains availability and visibility to all departments and medical staff regarding harms reduction.
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