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At Central Maine Healthcare our team members are committed to providing exceptional care and experiences for our community and for each other every day.

Position Summary:

Responsible for supporting a system wide approach to measure, evaluate and improve patient safety across Central Maine Healthcare. Oversees core measure chart abstraction, reporting and service-line related registry databases for CMH, such as cardiovascular and surgical. Responsible for ensuring the system is compliant with the Maine Sentinel Event law by working proactively to identify, investigate and report sentinel events. Conducts a system wide approach to root cause analysis (RCA), personally conducting, coordinating, facilitating and participating in patient safety related assessments, improvement efforts, root cause analysis and failure modes effects analysis. Will convene, coordinate, lead and align the system leaders in their responsibilities to identify patient safety risks. Chairs the system patient safety committee, whose responsibility is to review individual safety and risk events, determine trends, recommend and implement actions to minimize patient harm, and support the efforts of the organization to achieve zero harm. Support/facilitate the implementation of systems and processes that promote a culture of safety and reduce patient harm. Coordinates communication with bedside staff and other relevant stakeholders regarding improvements related to adverse events. Manages sentinel event communication and follow-up with appropriate external agencies. This position provides consultation in the development and monitoring of the outcomes of performance improvement initiatives regarding serious adverse events. Identifies areas needed for improvement in order to achieve zero patient harm. Tracks completion of sentinel event action plans including performance of related audits to ensure sustainable change. Ensures the organization meets Joint Commission and Centers for Medicare and Medicaid Services (CMS) standards and regulatory requirements related to Patient Safety. Assists with regulatory preparedness and response activities. Must have strong collaboration skills in order to be successful in this role.

Education and Experience:

+ RN, Bachelor’s preferred

+ Current clinical license

+ 5 years of clinical experience or demonstrated understanding of ambulatory and acute care clinical practices

+ Previous experience in performance improvement activities preferred

+ Certified Professional in Healthcare Quality (CPHQ) certification encouraged

Essential Duties:

+ Oversees core measure chart abstraction and reporting.

+ Oversees service-line related registry databases for CMH, such as cardiovascular and surgical.

+ Oversees and participates in daily mortality review through review of electronic health record to identify potential unreported sentinel events.

+ Oversees and participates in mortality reviews in MIDAS focus study.

+ Collaborates with Risk department to identify potential sentinel events that have been reported as an adverse event in MIDAS.

+ Oversees investigation of potential sentinel events to determine if sentinel event criteria are met.

+ Notifies organizational leadership when it is determined that a sentinel event has likely occurred.

+ Oversees and participates in reporting of sentinel events to the Maine Sentinel Event Team (SET) using the proper paperwork.

+ Organizes, facilitates and documents root cause analysis (RCA) with key stakeholders to identify the root cause, contributing factors and process changes intended to prevent similar events.

+ Submits RCA paperwork to the Maine SET within their established timeline.

+ Tracks completion of sentinel event action plans including the performance of related audits.

+ Participates on and/or facilitates harm reduction committees and performance improvement teams i.e. Multidisciplinary Fall Committee, Pressure Injury reduction, mortality reduction, code blue review committee.

+ Consults other departments as appropriate to collaborate in patient care and performance improvement activities. Facilitates needed changes as directed.

+ Engages key stakeholders in leading necessary improvement work.

+ Reviews program results with Director prior to submission.

+ Provides information on status of projects to medical and hospital staff on performance and areas of improvement needed.

+ Prepares high-level reports for communication to leadership and board committees.

Supports Internal PI Projects; Data management:

+ Provides clinical data analysis support to CMHC departments, committees and medical staff on key quality and patient safety initiatives.

+ Compiles, analyzes and reviews data for quality reports. Creates various quality reports for distribution within the organization.

+ Formats PI data in charts, graphs with accompanying analysis, summary and findings for presentation at committee and Board meetings.

+ Able to review and analyze internal data reports, external reports and other sources.

+ Consults other departments as appropriate to collaborate in patient care and performance improvement activities. Facilitates needed changes as directed.

Departmental Performance Improvement goals and responsibilities:

+ Assists department and Director in the writing, review and revision of departmental policies and procedures, ensuring compliance with regulation other professional organization guidelines (i.e. CDC, etc.)

+ Assists with preparation for and participates in all regulatory surveys; Joint Commission, State Licensing Review, HCFA (CMS) Validation Surveys, etc.

+ Demonstrates knowledge and competence in database use; creates documents, enters data and generates reports in Microsoft excel and MIDAS.

+ Demonstrates knowledge and competence in data management via electronic environment, including charts, graphs, grids and other accepted forms of data collection, analysis and display.

+ Communicates appropriately to physicians, staff, Director and administrative team.

+ Attends and facilitates Performance Improvement task force meetings as requested

If you are passionate about making a difference and are looking for your next great career opportunity, we look forward to reviewing your application!

AT CENTRAL MAINE HEALTHCARE YOU ARE AT THE CENTER OF EVERYTHING WE DO

Our why, our purpose, drives every decision and action we take as a healthcare system. We strive everyday to deliver exceptional care, and to improve our community. We are a non-profit organization that is breaking the traditional healthcare mold by bringing our patients and their family’s high value, low cost, and award-winning care while focusing on creating an exceptional experience for them; all within their communities. To accomplish this, we only hire individuals who are committed to excellence, who embody the principles of our CMH Experience Service Standards, and who are ready to step in and help their fellow team members achieve those exceptional results for our patients, their families, and the community.

Central Maine Healthcare System

The organization is broad in its footprint, with three (3) hospitals in Bridgton, Lewiston, and Rumford, and over 75 individual practices within our Medical Group. Lewiston’s Central Maine Medical Center is a certified and award-winning level two trauma center, along with our Central Maine Heart and Vascular Institute and the upcoming highly anticipated launch of our comprehensive state of the art cancer treatment center. Both Bridgton and Rumford Hospitals are four (4) star accredited acute care hospitals, and our Medical Group and Maine Urgent Care Centers have won multiple awards within their specialties. As a system we are a six-time winner of the Leapfrog Safety A Rating since 2019, representing some of the highest quality care and outcomes nationwide. Our awards and accolades are only possible as a result of our commitment to culture, and a focus on safety and inclusion, in each of our patient’s experiences and in the experiences we create within our teams.

If you are a person who is looking for a way to give back to your community, to help improve the lives of patients or those who care for our patients, want to be part of a growing organization that is setting the bar for Maine healthcare, apply to join Central Maine Healthcare today!

Diversity and Equal Employment Opportunity

CMH actively promotes diversity in its workforce at all levels of the organization. We strive to create and maintain a setting where we celebrate cultural and other differences and consider them strengths of the organization. CMH is an equal opportunity workforce and no one shall discriminate against any individual with regard to race, color, religion, sex, national origin, age, disability, sexual orientation, gender identity, genetic information or veteran status with respect to any offer, or term or condition, of employment. We make reasonable accommodations to the known physical and mental limitations of qualified individuals with disabilities.