Provides administrative and clinical review and administrative support for the DoD’s implementation of the American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) program. This includes but is not limited to, clinical screening, data compilation documentation and entry into the DoD NSQIP data base of all eligible patient cases within the medical treatment facility.  The SCNR also works closely with the members of the Department of Surgery to identify opportunities for clinical quality improvement. The program collects data on cases, such as demographics, surgical profile, preoperative, intraoperative and post operative mortality and morbidity outcomes for patients undergoing surgical procedures in both inpatient and outpatient settings.

• Responsible for the identification of surgical patients for inclusion in the program registry through the application of strict program inclusion/exclusion criterion and randomization protocol.
• Responsible for the reliable collection of pre-operative, operative, and post-operative data components for the program through the effective utilization of the hospital medical record system.
• Responsible for meeting the accrual requirement of cases per year through the correct application of the program’s randomization protocol.
• Attends weekly Morbidity & Mortality conferences to ensure reliable data collection of postoperative occurrences.
• Demonstrates applicability of the methodology and the reliability of definitions utilized by reviewers within the program through Inter-Rater Reliability (IRR) testing.
• Responsible for identifying areas for streamlining and process improvement in the data collection process.
• Responsible for utilizing software applications available at the site for data collection and analysis.
• Responsible for the accurate and timely entry of data into the program’s website and assuring the transmission of completed data.
• Responsible for reviewing weekly site accrual report on the website and responding to accrual report alerts.
• Contacts patients and/or families via telephone and/or written communications post-operatively for the purpose of identifying possible occurrences associated with surgical procedures performed at the hospital.
• Serves as an educational resource on the ACS NSQIP for internal and external audiences by developing educational material and delivering presentations.

• Knowledge of professional nursing principles and procedures in surgery, either the operating room, intensive care unit or inpatient surgical ward.
• Must have knowledge of accreditation standards, privacy and confidentiality requirements, such as, The Joint Commission and HIPAA.
• Computer skills and abilities. Must be comfortable using Microsoft Office programs (Word, Excel, PowerPoint and Access), Outlook (e-mail), and Internet.
• Ability to collect, evaluate and analyze data and reports.
• Quality improvement and patient safety knowledge.
• Baccalaureate in science from a program approved by the Accreditation Center for Education in Nursing (ACEN, formerly NLNAC) or the Commission on Collegiate Nurse Education (CCNE)
• License/Certification. Current, active, full, and unrestricted License to practice Nursing. Nurse applicants must be a current U.S. licensed Registered Nurse.
• License cannot be under investigation nor have any adverse action pending from a Nursing State Board or national licensing/certification agency.
• Minimum three (3) years’ experience in inpatient surgical nursing or as a surgical care reviewer required.
• Equivalent combinations of education and experience may be qualifying if approved by the requesting location and the Contracting Officer. If education or experience is used to meet the specialized requirements of this position, it must be directly related to the duties and responsibilities of this position.
• Work Environment/Physical Requirements. The work is primarily sedentary. However, there may be some physical demands. Requirements include prolonged walking, standing, sitting or bending.

• License/Certification. Current, active, full, and unrestricted License to practice Nursing. Nurse applicants must be a current U.S. licensed Registered Nurse.
• Possess current Basic Life Support (BLS/CPR) certification.