Job Description

_ General Summary_

Works independently under limited supervision of the Director. Provides leadership in the development, implementation and evaluation of programs with focus on clinical policy and policy integration for Nursing & Patient Care Services (PCS) for the Midtown and Downtown Campuses. Provides strategic leadership and expertise in evidence-based policy to achieve optimal quality, patient safety, clinical excellence, discovery, compassion, diversity, and integrity that align with the mission, vision, and values of the organization.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. These are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. Oversee UMMC Nursing & PCS clinical polices, protocols, and guidelines. Utilize PolicyStat® software and ensure policies are current.
2. Review current Nursing & PCS clinical policies and identify similarities to facilitate consolidation of policies. Identify and engage with key stakeholders and policy owners to ensure similar policies are merged.
3. Manage integration of Downtown and Midtown Campus Nursing & PCS clinical policies, guidelines, protocols, where appropriate.
4. Ensure Nursing & PCS clinical policies reflect best evidence and latest trends in clinical practice.
5. Collaborate with the Chief Clinical Officer and Associate Chief Clinical Officer to develop and implement an evaluation process for policies to ensure policy sustainability.
6. Provide monthly report to Provision of Care and other committees on the status of Nursing & PCS clinical policies.
7. Collaborate with the Vice President of Regulatory Affairs & Compliance on ensuring Nursing & PCS clinical policies that have completed the approval process are implemented.
8. In collaboration with Regulatory Leadership, ensure all Nursing & PCS clinical policies, protocols, and guidelines meet TJC and CMS standards and coordinate the alterations as per prescribed policy.
9. Provide Nursing & PCS clinical policies, protocols, and guidelines for review at the request of Regulatory during TJC and CMS surveys.
10. Identify units with paper Nursing & PCS clinical policies, develop and implement plan to convert to PolicyStat®.
11. Collaborate with Senior Leadership and the Chief Clinical Office in the evaluation of new and revised policies to ensure policies, protocols, and guidelines meet Nursing & PCS clinical standards.
12. Advocate for the integration of DTC/MTC policies within UMMS.
13. Collaborate with the UMMS Director of Clinical Practice and Policy Integration to identify Nursing & PCS clinical policies to be integrated with UMMS.
14. Identify practice changes in local Nursing & PCS clinical policies to facilitate integration with UMMS policies.
15. Communicate proposed changes of UMMS policies/procedures to local stakeholders for feedback and approval.
16. Collaborate with Quality & Safety and participate in Root Cause Analysis (RCA) and Quality of Care (QOC) to identify policy-related practice concerns and report findings to policy owners and the Center for Clinical Excellence and Professional Development.
17. Address Compliance and Regulatory requirements not being met from a clinical policy perspective to include: documentation and variations in practice.
18. Collaborate with the Directors of Quality & Safety, Regulatory Compliance, and Clinical Effectiveness in determining areas of need and developing appropriate clinical policies to address variations in practice.
19. Identify and analyze hospital outcome data to determine compliance with and effectiveness of UMMC Nursing & PCS clinical policies, protocols, and guidelines.
20. In collaboration with the Director of Nursing Inquiry, identify practice change recommendations that impact Nursing & PCS practice and policy development.
21. Manage communication to hospital staff on policy-related clinical practice updates.

Qualifications

_ Education and Experience_

1. A Master’s degree from an accredited college or university in Nursing or Healthcare field is required. A doctoral degree (DNP) degree preferred.
2. Licensure as a Registered Nurse in the State of Maryland, or eligible to practice due to Compact State agreements outlined through the Maryland Board of Nursing, is required.
3. A minimum of 5 years of hospital experience is required, with progressive leadership and related experience in project management
4. Knowledge of policy development and policy management systems

Knowledge, Skills and Abilities

1. Clinical and professional knowledge regarding current issues affecting healthcare delivery, quality management and professional practice is required. Knowledge regarding group dynamics, organizational change and methodologies for affecting change through leadership are required.
2. Ability to independently develop and manage organizational level projects. Ability to plan, organize and follow through on projects.
3. Expertise in translation of clinical research in nursing practice.
4. Demonstrated success in a leading, exhibiting teaching, and mentoring skills. Demonstrated effectiveness in a consultative role at the organizational level.
5. Knowledge of database management and data analysis is required.
6. Knowledge of policy development and utilization of policy management software required.
7. Highly effective written and verbal communication, presentation and interpersonal skills are required to work successfully with various levels of clinical, administrative and management personnel including senior executives.

Additional Information

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