BASIC PURPOSE OF THE JOB

This position is responsible for establishing and coordinating a multidisciplinary approach to neonatal and pediatric surgical quality and performance improvement across the continuum of care. In collaboration with the Medical Director for Children's Surgery, the Chief of Surgery, and the Director of Quality & Patient Safety, the manager is expected to provide program development, implementation, and ongoing evaluation in accordance with national standards necessary for achieving and maintaining Level II Children's Surgery Verification status as granted by the American College of Surgeons (ACS). Collaborates with physicians and hospital staff to ensure optimal patient care through the use of evidence-based practice, clinical best practice models, culture of safety, appropriate staffing and technologies and continuous process improvement measures. Demonstrates a commitment to patient safety and quality and ETCH core values. Leads the administrative, strategic and clinical direction of the Surgical & Trauma Quality and Safety Program through development, implementation and ongoing evaluation of Children's Surgery & Trauma Verification Status.

REPORTS TO

• Medical Director for the Children's Surgical Verification Program and Director of Peri-operative Services

JOB REQUIREMENTS

Supervisory Responsibilities: Yes

Minimum Education: Bachelor's Degree/BSN required; Masters preferred

Degree: Nursing or healthcare related field

License/Certification Required: RN in state of Tennessee and PALS required; CPHQ preferred.

Minimum Work Experience: 3-5 years of surgery clinical experience and 1 year minimum of supervisory experience required. Pediatric experience preferred. Surgical Manager or Educator experience preferred.

REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES

• Proven on the job leadership skills working with multidisciplinary patient care providers in a hospital setting.
• Leader who can set clear goals for their team, coaches to improve performance, and inspires and drives positive outcomes. A leader who can communicate information in a timely manner, innovative and encourages new approaches, and employs strategies to overcome resistance to change.
• Teamwork and collaboration to accomplish common goals, constructively raise concerns, and identify solutions using problem solving approaches.
• Knowledge of medical terminology, surgical procedures, ICD10 coding, and regulatory standards (Joint Commission, CMS, AORN, AMA, ACS, etc).
• Ability to work independently on assigned projects and to recommend improvements to the process to medical and hospital staff.
• Excellent organizational, written and verbal communication skills, and the ability to prioritize multiple work projects and tasks. Confidentiality is an imperative character trait for this position.
• Moderate keyboarding speed.
• Must be able to work effectively with common office computer software (such as Microsoft Office), the electronic medical records system, spreadsheets, graphical programs, and NSQIP database. Statistical knowledge and previous statistical analysis preferred.

DUTIES AND RESPONSIBILITIES

• Lead efforts to obtain and maintain Children's Surgery Verification (CSV) with the American College of Surgeons, meeting all regulatory compliance and standards, as applicable. The incumbent will coordinate all responses to the verification application and site visit, documenting and facilitating issue resolution and corrective action plans.
• Collaborates with medical and hospital staff across the continuum of children's surgical care, including planning and implementing of clinical protocols, clinical pathways and practice management guidelines, monitoring care, and serving as an expert resource for clinical practice both within the facility and at other outside system entities. Oversees the development and review of care protocols, policies and procedures that promote organized and effective pediatric surgical care.
• Facilitates the development and implementation of intra-facility and regional staff development educational programs including hospital nursing and physician continuing education programs. Facilitates and participates in case review, standardizing practice guidelines, and directs community education for appropriate transfers to inpatient surgical services or intra-facility transfers to a higher level of care.
• Oversees the implementation of clinical program initiatives, including (but not limited to): core measures, surveillance, clinical data abstraction, and patient safety efforts. Works collaboratively with multidisciplinary teams to strategize, develop, and achieve goals. Works with the Acute Care/Trauma Committee, Quality Improvement Committee, and other hospital committees to coordinate surgical quality efforts.
• Formulates, drives, and leads projects using process improvement methodologies (e.g. Lean, Six Sigma, PDSA), project management strategies, facilitation, and change management to achieve improvements in operational and/or clinical outcomes.
• Provides ongoing evaluation of the effectiveness and efficiency of the pediatric surgical enterprise. Monitors clinical processes, outcomes and system issues related to quality of surgical care through the development of quality filters, audits, case review and root-cause analyses. Identifies trends and sentinel events and helps to outline corrective actions as applicable. Is involved in patient engagement efforts and monitors patient perception of the quality of care delivered. Participates on hospital root-cause analyses and assists in action plan follow-up as needed.
• In conjunction with the Medical Director of Children's Surgery plans, coordinates and conducts quality and safety meetings such as the Performance Improvement Patient Safety (PIPS) Meeting, Surgical Services Executive Committee (SSEC) Meeting, Acute Care/Trauma, Department of Surgery Meeting, Grand Rounds and Multidisciplinary Committees as appropriate. Sees that agendas, attendance, records/minutes and follow up are prompt, detailed, and accurate.
• Provides oversight and direct supervision of the collection, coding, validation, analysis, and distribution of data used to guide performance improvement activities for surgical registries. Designs processes to facilitate performance improvement activities, trend reports and research while protecting confidentiality.
• Supports clinical program, facility and corporate goals and initiatives. Attends and actively participates in system level meetings representing the facility. Presents/reports on progress to directors, administrators and leadership boards as assigned.
• Assists in annual strategic planning, operational, personnel and capital budgetary planning for the children's surgery program. Adheres to staffing and operational budgets as applicable. Completes and submits budget reports as required by facility. 
• Facilitates communication and collaboration to stabilize the complex network of many disciplines and departments that work in concert to provide high quality children's surgical care. Represents the children's surgery program on various hospital and community committees to enhance and foster optimal surgical care management.
• Assist Trauma Coordinator with review and performance improvement with the care of trauma surgical patients.
• Demonstrates excellent communication skills through verbal, written and presentation material as required for committees, management groups, administration, etc.
• Utilizes hospital resources and time respectfully and accountably.
• Willingly accepts any other assignment that may be requested.

PHYSICAL REQUIREMENTS

• Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
• Light lifting, pushing and pulling is required for 1-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending, and reaching is required. Keyboard/computer use and/or repetitive motions may be required.

Come work where you can make a difference everyday.