TOPS Surgical Specialty Hospital

Leads and directs all quality management activities for the hospital including patient care and relations, TJC compliance, risk management and safety, performance improvement, and infection control.

1. Philosophy
a) Supports TOPS Surgical Specialty Hospital ideology, mission, goals, and objectives
b) Performs in accordance with TOPS' policies and procedures
c) Follows TOPS' standards for ethical business conduct
d) Conducts self as a positive role model and team member
e) Recognizes patients' rights and responsibilities and supports them in performance of job duties
f) Participates in TOPS' committees, meetings, in-services, and activities
2. Communication
a) Communicates effectively and professionally with patients, visitors, physicians, and coworkers
b) Interacts with others in a positive, respectful, and considerate manner
3. Financial Practices
a) Uses facility resources appropriately and avoids wasteful practices
b) Reports wasteful practices
c) Analyzes work area and makes recommendations for potential cost-effective improvements
4. Compliance Program
a) Contributes to the progress and development of TOPS' adopted compliance program
b) Performs according to established compliance policies and procedures
5. Performance-Improvement Program
a) Contributes to the progress and development of TOPS' adopted performance-improvement program
b) Performs according to established performance-improvement policies and procedures
c) Objectively evaluates suggestions, grievances, and processes to identify opportunities to improve performance and quality of care
d) Participates in data collection activities to support the performance-improvement program
6. Safety/Risk-Management Program
a) Adheres to safety policies and procedures in performing job duties and responsibilities
b) Reports observed or suspected safety violations, hazards, and policy/procedure noncompliance to the safety officer or other designated person
7. Professional Competence
a) Participates in continuing education and other learning experiences
b) Shares knowledge gained in continuing education with staff
c) Maintains membership in relevant professional organizations
d) Seeks new learning experiences by accepting challenging opportunities and responsibilities
e) Participates in teaching programs @ TOPS for employees and physicians on topics of special interest and topics pertinent to surgery and other procedures.
f) Researches and submits pertinent articles for review at staff meetings
g) Assists with orientation and training of new personnel and acts as a resource person for problems related to patient care
h) Welcomes suggestions and recommendations
8. Duties
a) Participates as a team member in support of the total peri-operative process
b) Organizes time, equipment, supplies, and personnel to provide effective and efficient management
c) Organizes nursing activities efficiently and effectively
d) Oversees the Employee Health Nurse with monitoring employee health files to keep current vaccinations, immunizations & labs
e) Oversees the Employee Health Nurse with the monitoring of Employee "On the Job" Injury / Exposure Incidences relating to employee injury, illness and exposure
f) Supplies education material and information to employees as necessary
g) Familiar with community health and needs of Health Care Workers in relationship to Blood Borne Pathogens.
h) Familiar with OSHA Standards, The Joint Commission Standards, and the CDC Standards.
i) Adheres to and facilitates the USPI EDGE Program
j) Oversees the Infection Preventionist in providing Employee Education for Infection Prevention, surveillance and assessment of infection control practices related to Standard Precautions, Transmission Precautions and Exposure Control, and reporting activities related to infection control to the Quality Committee
k) Oversees the review and revision of the Infection Control Policy and Guidelines for program scope, objectives, performances and effectiveness at least annually.
l) Responsible for Quality Improvement Programs
m) Oversees the quality staff with chart auditing and monthly / quarterly Core Measure Reporting
n) Oversees the auditing of medical records per government regulatory agencies and accrediting bodies recommendations
o) Initiates actions that are intended to correct, reduce or prevent situations that have potential or actual risk to patient, staff or organizational viability
p) Oversees all Quality Meetings
q) Oversees the Cerner Analyst and ensures that the Meaningful Measures are completed.
r) Oversees the Case Manager and assists with the credentialing and FPPE/OPPE processes.
s) Actively coordinates, participates and educates all staff in Quality Improvement projects
t) Uses research finding for nursing educational activities
u) Performs other tasks and duties as assigned in an efficient, effective, and cost conscious manner, complying with all USPI's policies, procedures and regulations.

#USP-ST

#USP-123

#LI-JB1

1. Cooperative work attitude toward co-employees, management, patients, visitors, and physicians
2. Ability to promote favorable facility image with physicians, patients, insurance companies, and general public
3. Ability to make decisions and solve problems

4. Accuracy

5. Attention to detail
6. Timeliness
7. Organization
8. Leadership
9. Physical stamina for working extra hours, if needed

10. Attendance
11. Punctuality
12. Ability to follow instructions
13. Ability to meet deadlines

1. High school graduate or GED certificate recipient
2. Graduate of accredited school of nursing with a BSN or working towards it, MSN preferred.
3. RN with active license in appropriate state
4. BCLS /ACLS /PALS certified
5. Leadership qualities
6. Strong ethical and moral character references
7. Language skills adequate for high-level written, interpersonal, and telephone communication in American English
8. Computer Literacy
9. Quality certification or working towards it.

About United Surgical Partners International, Inc

United Surgical Partners International (USPI), a subsidiary of Tenet Healthcare Corporation (NYSE: THC), operates the largest ambulatory platform in the country. With more than 465+ facilities across the United States, the company serves patients in ambulatory surgery centers and surgical hospitals. For more information, please visit www.uspi.com. USPI’s mission is simple, but the gravity of it is profound. We care for every patient and their family as if they were our own. Each patient, each family, each and every time.

Connections working at United Surgical Partners International, Inc