The Clinical Coordinator of Sepsis promotes quality of care for patients via effective application of data-driven performance improvement efforts and close collaboration with hospital and critical care leadership, staff, and medical staff. This role is responsible for leading interprofessional team efforts to ensure evidence-based practices and clinical practice guidelines are considered in performance improvement activities related to sepsis and critical care medicine. ENTRY REQUIREMENTS Graduate of an accredited School of Registered Nursing and currently registered in good standing with the State of Michigan. BA or BS degree in healthcare-related field required. For those hired into an RN position after January 1st, 2015, it is required to obtain a BSN within 5 years of start date. Master’s degree in related field preferred. Minimum of five years’ experience in an acute care setting, including at least three years’ critical care nursing experience. Demonstrated leadership in process improvement and project management preferred. Lean experience desired. Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make reliable independent decisions using analytical problem-solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented. Ability to proficiently create and utilize databases, word-processing, spreadsheets, presentation programs and other software relevant to the job. Requires technical knowledge of hospital applications data-query software spreadsheets and report-generating software. Internet skills and literature search capabilities. Requires highly developed understanding of the electronic health record and its functionality and use Requires highly developed written, oral, and presentation communication skills; an ability to communicate with internal and external customers; employing a high level of tact and diplomacy; must possess strong consensus building skills. Demonstrates knowledge of confidentiality as it pertains to HIPAA and the handling of information sensitive to Munson Healthcare. Possesses knowledge of the clinical capabilities of Munson Medical Center as well as knowledge of hospital organization and department functions. Provides administrative, technical, and coordinating support to ensure effective, timely, quality assessment and performance improvement activities. ORGANIZATION This position reports to the Director of Organizational Quality. Also has accountability to the MHC Chief Quality and Safety Officer. Works in close collaboration with the physician sepsis champion, as well as nursing, pharmacy, and medical staff leaders across the organization. SPECIFIC DUTIES
Supports the Mission, Vision and Values of Munson Healthcare.
Embraces and supports the Performance Improvement philosophy of Munson Healthcare.
Promotes personal and patient safety.
Demonstrates effective customer service/interpersonal skills at all times. Applies techniques of problem solving, active listening, negotiation and strong consensus building skills across multiple disciplines.
Promotes use of risk reduction strategies. Serves as a role model for patient quality and safety throughout the organization. Works with multidisciplinary teams to identify and investigate patient care quality/safety issues, events, or trends; recommends prevention strategies to improve healthcare delivery using process improvement techniques (e.g., root cause analysis, control and run charts).
Develops, designs, and maintains relevant electronic data systems (i.e. clinical data systems that support facility information needs for the purpose of performance improvement and assessment of clinical quality/patient safety).
Assists in design, installation, implementation and evaluation of existing or new database applications, tables and files
Oversees the performance of day-to-day operation and maintenance of software systems to include updates of the system as indicated, including periodic testing of integrity of the systems/data
Recommends improvements to the systems as needed.
Works collaboratively with Information Systems to implement relevant electronic data systems (i.e. cloud-based sepsis alerting technology, CERNER Sepsis Advisor & Quality Management).
Maintains knowledge of current PI methodologies and clinical informatics through regular review of literature, conference attendance, participation in professional organizations, etc.
a) Analyzes, interprets and synthesizes relevant literature and research studies to maintain knowledge of updated and current practices in specific area of interest.
b) Provides customers with up to date information relevant to Performance Improvement and specific area of responsibility.
c) Understands concepts of Six Sigma/Lean principles and tools.
d) Maintains baseline knowledge of Joint Commission standards, National Patient Safety Goals,
and other regulatory requirements impacting matters within the assigned scope of responsibility; ensures that these factors are considered and integrated into PI activities.
e) Expected to maintain professional growth and development. Demonstrates an ongoing commitment to learn.
Comprehends data, trends, and measurement outcomes. Communicates complicated concepts in a clear and understandable manner to health care professionals both verbally and in written form. Able to present to individual providers as well as groups, both internal and external as requested.
Performs data abstraction for sepsis measures and provides inter-rater reliability for others responsible for sepsis data collection.
Manages data, maintaining high standards for accuracy and assuring data integrity.
Develops and implements data collection processes: provides research, benchmarking, analysis and summary
Assists in the development of outcome assessment tools for the continuum of care. Responsible for analyzing and reporting patient care outcomes data from various databases and identifying plans for improving outcomes, length of stay, and resource utilization.
Produces analysis and trending reports that include graphic presentations and statistical summaries for use by management, and/or clinical staff as well as appropriate facility, system, and external customers in accordance with established timelines. Composes grammatically correct and technically accurate case review summaries and reports.
Collaborates with Clinical Quality leadership or designee to prepare required (regularly scheduled and ad hoc) reports to the Quality and Patient Safety Committees, Medical Staff committees, and Hospital Departments as appropriate. Collaborates with the physician champion in the presentation and dissemination of information. Collaborates with Clinical & Business Intelligence department to ensure relevant data is readily available to frontline users.
Provides patient outcomes information and physician-specific outcomes data for medical staff performance improvement when requested.
Identifies processes, outcomes and trends where improvements could be made and proposes recommendations.
Co-chairs MMC Sepsis Committee meetings with Physician Champion.
Collaborates with medical staff, nursing, and ancillary services in the application of continuous performance improvement principles, standards and tools.
Facilitates application of problem-solving methodologies, emphasizing the effectiveness and efficiency of evidence-based and data-based decision-making in performance improvement activities.
Establishes standards and procedures for projects such as tracking, reporting, recordkeeping and documentation; monitors progress on key quality initiatives and indicators, leading towards achievement of department, service line, and organizational goals. Keeps appropriate parties apprised of overall progress and monitors project results for significant deviations; proposes workarounds and alternative actions to ensure that timelines and deliverables are met; reviews project deliverables to ensure they meet standards and objectives.
Assists in the development and revision of critical pathways and trending of variances as appropriate.
Serves as a resource to colleagues throughout the medical center.
a) Establishes a process for ongoing monitoring for early identification of sepsis patients and
compliance with evidence-based interventions and processes. Provides real-time support for
caregivers via a sepsis surveillance program, prospectively identifying those patients who are on
sepsis bundle or should be, provides real-time education to medical and nursing staff in support
of evidence-based guidelines, and identifies and assists with removal of barriers.
b) Collaborates with leadership to identify and discuss performance improvement strategies and
opportunities as they relate to organizational mission, vision, and values, clinical outcomes, and patient safety goals.
c) Analyzes and assesses clinical practices for opportunities to improve healthcare delivery.
gains consensus as to performance improvement projects to be undertaken; assists in the
development and evaluation of standards, procedures, processes, and automated tools that
support established goals and regulatory requirements.
e) Serves on hospital, professional, and community committees as appropriate; provides
ongoing consultation and education for hospital policies, procedures and PI/Patient Safety programs/activities designed to meet regulatory and accrediting agency requirements (i.e. Joint Commission, CMS, IHI, DHHS, and Peer Review organizations)
f) Serves as representative of Clinical Quality Department at Medical Staff and hospital
committees as assigned.
g) Assists in identification of educational needs of medical and nursing staff through
participation in data registries and subsequent outcome analysis. Communicates identified
educational needs to CME Coordinator and Staff Development personnel.
h) Assists in development and/or presentation of continuing education related to specific areas
of interest/responsibility.
Performs other duties and responsibilities as assigned.
