Works under the supervision of the Trauma/Stroke Program Manager to provide support, consultation, compliance to evidence-based care, and patient safety practices in aligned service area. Supports the organization in communication of information from the aggregation, trending, analyzing, and evaluation of current practices and outcomes. Facilitates and drives improvements in clinical performance initiatives and helps to maintain regulatory compliance. Performance relies on general nursing/clinical knowledge, including pathophysiology, pharmacology, and regulatory requirements. Advanced computer skills are required to proficiently conduct the following: develop presentations, concurrent and retrospective chart abstraction, database submissions and entries, and analyze variations in data for use in improvement opportunities. Provides Medical Staff reviews and supports functions of Medical Staff quality. Will be assigned databases for abstracting data and compiling statistical reports to Regulatory bodies, Leadership, and Physician groups. Works with information systems and tools to obtain data needed for clinical process improvements or provide data on request from internal customers. Research and communicate best practices for various aspects of clinical healthcare • Regulatory/compliance: Knowledge of regulations and strategies for state, CMS and TJC compliance • Leadership: Annual and ongoing review of standards, order sets and forms. Stroke Team PIPS and peer review: agenda, case discussions, minutes review, attendance reports. Budget and financial accountability. • Education: Annual review and update of required hours education. Create and instruct nursing stroke classes. Develop and instruct ED and Critical Care staff competencies/orientation. Provider education. Resource to outlying Mosaic facilities. • Outreach: Timely EMS feedback, stroke education, and regional representation of Mosaic Stroke program. Develop and instruct stroke prevention and recognition classes for general public. Track provider or nursing opportunities for improvement. Coordinate education. • Process Improvement (PIPS): Indicator development, loop closure and issues log, feedback to providers and nursing. Facilitates the completion of monthly reports. Provides feedback to coordinated care manager regarding data needs. Conducts audits of patient medical records for performance improvement, tracking, trending, and comparison purposes. Real-time response to alerts to facilitate processes • Abstracts data from concurrent and retrospective charts, as well as computerized data systems using approved criteria for routine and special studies • Provides reports/presentations on quality for work groups and may include varied audiences of stakeholders, including Medical Staff, Senior Leadership, Administration, and C-Suite • Actively participates in regulatory readiness and survey processes • Registrar: Determine patients who meet qualifications to be entered into “Get With The Guidelines” Stroke Registry. Provides trending and comparative reports on numerous issues. Facilitates the completion of monthly reports. Provides feedback to coordinated care manager regarding data needs. Conducts audits of patient medical records for performance improvement, tracking, trending, and comparison purposes. Review current literature and acquire reference materials for the Stroke program. • Stroke Rapid Response: Respond to stroke alerts during office hours. Resource/Support during time-critical events. Maintain ER competencies (PALS, ACLS, TNCC, AVADE, yearly assigned competencies) • Other Duties as Assigned: Back up staff to the ER for mass-casualty or influx of high-acuity patients. meeting attendance as required. Education • Nursing diploma or degree from accredited school of nursing. - Required • Bachelor's Degree - Preferred Work Experience • 5 Years - Emergency or critical care nursing - Preferred Licenses and Certifications • Registered Nurse (RN) - State Licensure/Or Compact State Licensure - licensed in State of Missouri or Kansas, depending upon designated work location - Required Upon Hire • Basic Life Support (BLS) - Required within 90 Days • Advanced Cardiac Life Support (ACLS) - Required within 1 Year • Pediatric Advanced Life Support (PALS) - Required within 1 Year • Trauma Nursing Core Course (TNCC) - Required within 1 Year • Driver's License - Valid In State - Required Upon Hire • MRS Course - Required within 60 days Travel Requirements • Must be able to travel between various system facilities and off-site locations as needed. - Required Skills and Abilities Essential Technical/Motor Skills • Knowledgeable in computer systems: Word, Excel, and Graphs. Requires basic typing skills. Knowledgeable in interpreting statistics. Excellent written and verbal communication skills. Demonstrates leadership skill with innovative resolution to problems. Demonstrates desire to succeed. Excellent analytical, judgment and people skills. Ability to design, implement and follow up test plans. Ability to troubleshoot and document multi-system issues. Require general conceptual knowledge of servers, interfaces, configuration, and databases. Ability to educate staff using adult learning tools. Interpersonal Skills • Must possess excellent oral and written communication skills and present a positive image for the organization. Must be motivated, able to work independently, be a strong facilitator and have excellent follow through skills. Must be able to interact with people in a professional, diplomatic, and sensitive manner and ensure that appropriate confidentiality is maintained. Essential Physical Requirements • Manual dexterity, typing etc. Frequently required to perform simple typing and writing. Frequently requires good hand eye coordination. Mobility: frequently required to sit for prolonged periods of time. Requires ability to hear normal sounds with some background noise as in answering telephone, paging systems, intercom, etc. Essential Mental Abilities • Analytical skills necessary to interpret quantitative and qualitative data relevant to service line. Effective organizational, planning, negotiating, coaching, and conceptual thinking skills. Essential Sensory Requirements • Must be able to communicate via telephone and in person. Must be able to review reports and organization goals for quality and accuracy. Communicate effectively with all levels of staff and customers. Exposure to Hazards • Must be prepared for disasters, potential blood, and body fluids. Exposed to environmental hazards such as might accompany an incoming patient. Other Skills and Abilities