Coordinator for Nursing Policy and Practice Standards - RN
Randallstown, MD
NORTHWEST HOSPITAL
CLINICAL EXCELLENCE
Full-time - Day shift - 7:30am-4:00pm
RN Other
85312
Posted:
September 3, 2024
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Summary
Join our Team! Care Bravely with us!
Position Summary:
The Coordinator for Nursing Policy and Practice Standards (CNPS) is part of Patient Care Services, reporting directly to the Director of Clinical Excellence, and is responsible for identifying, facilitating, and evaluating standards and policies across PCS. This portfolio of work ensures standards and policies comply with The Joint Commission, Centers of Medicare and Medicaid Services, and applicable standards and regulations while upholding the highest standards of care. The CNPS will coordinate evidence-based quality improvement initiatives across the hospital and through collaboration within the health system. Manages Patient Care Services response to regulatory inquiries.
Essential Functions:
Policy Management
The CNPS will support the day-to-day management of a portfolio of work and projects, focusing on providing organizational recommendations for policy alignment and structure for policy integration.
Evaluates, revises, and assesses ownership and necessity of PCS policies and procedures aligning with evidence-based practice and regulatory requirements.
Leads the integration and appropriate nursing and interdisciplinary feedback into document development and revision.
Plan, develop, implement, and organize a system for efficient management of Patient Care Services policies.
Ensures timely postings and efficient organization of the documents.
Provide policy interpretation guidance to PCS staff to ensure consistent compliance with policies.
Assesses clinical practice and policies to comply with The Joint Commission, Centers for Medicare and Medicaid Services, and standards and regulations.
Facilitates dissemination of PCS policy and procedure revisions and updates, including, but not limited to, the Quality Oversight Committee (QOC), Formulary Review Committee (FRC), and Medical Executive Committee (MEC).
Evidence-Based Quality Improvement Initiatives
Oversight of evidence-based quality improvement initiatives.
Promotes identifying clinical problems and searching for evidence in the literature to validate or change practice. Mentors staff in knowledge-seeking behaviors to address clinical questions.
Conducts literature review and synthesis and ensures that PCS policies reflect current evidence-based practice recommendations.
Provides leadership in designing, implementing, and evaluating process improvement initiatives.
Incorporates the evidence, patient preferences and values, and clinical expertise into policies, procedures, and clinical practice standards as appropriate.
Leadership
The CNPS provides strategic leadership and expertise in developing and implementing clinical standards and policies.
Serves as a key member of the nursing leadership team, participating in applicable leadership meetings and providing policy expertise.
Effectively leads intra- and interdisciplinary teams through evidence-based practice improvements, review, and policy revision.
Identifies and mitigates barriers during policy development and review, including practice and/or process inconsistencies.
Anticipates possible consequences of systems change and develops proactive strategies to address potential barriers.
Convenes teams of key stakeholders for large-scale policy and practice change coordination.
In partnership with Accreditation, support PCS response to regulatory surveys.
Collaboration
Collaborate with stakeholders and content experts across the organization to review and revise policy, procedure, and clinical practice.
Lead and organize document management, data management, and preparation for the policy and procedure review process utilizing a policy management system. Partner with interdisciplinary teams to develop resources for education and implementation.
Submit requests for Powerplan changes, Electronic Medical Record (EMR) modifications, form changes, Marketing requests, Care Connects, and development as needs are identified during the policy revision process.
Advocacy
Promotes policy and practice standards conducive to providing ethical care.
Qualifications/Requirements
Seasoned professional knowledge; equivalent to a Master's degree; knowledge in more than one discipline. MS is preferred, as is a strong background/experience in policy review, editing, and writing.
Experience: 5+ years
Maryland Registered Nurse License
American Heart Association BLS Certification
Specialty nursing certification preferred
Additional Information As one of the largest health care providers in Maryland, with 13,000 team members, We strive to CARE BRAVELY for over 1 million patients annually. LifeBridge Health includes Sinai Hospital of Baltimore, Northwest Hospital, Carroll Hospital, Levindale Hebrew Geriatric Center and Hospital and Grace Medical Center, as well as our Community Physician Enterprise, Center for Hope, Practice Dynamics, and business partners: LifeBridge Health & Fitness, ExpressCare and HomeCare of Maryland.
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