Description
Summary of Position:
This position supports, coordinates and facilitates quality management, patient safety, regulatory, and performance improvement activities. This role serves as a resource to employees, management, physicians and teams on quality management activities and will handle patient sensitive and confidential information.
Qualifications
Education:
• Completion of an accredited nursing program required
• Bachelor's degree in healthcare related field preferred
Experience:
• Minimum of three (3) years acute care healthcare experience required
• One (1) year healthcare-related quality management/performance improvement experience (e.g., participates in clinical ladder, PEP, or unit-based teams)
Knowledge/Skills/Abilities:
• Excellent critical thinking, data analysis, team building, and leadership change management skills preferred.
• Experience in quality management/performance improvement methods, tools and techniques strongly preferred.
• Experience as stroke coordinator, sepsis abstractor/coordinator, ACS trauma coordinator, STEMI/STS abstractor/coordinator, AAOS joints coordinator, patient safety officer, or performance improvement coordinator preferred.
• Knowledge of The Joint Commission standards, California Title 22 regulations, and CMS Conditions of Participation preferred.
• Knowledge of Word, Excel, PowerPoint and supporting computer programs.
• Knowledge of data reporting and regulatory/accreditation requirements for acute and ambulatory care services and federal, state and local healthcare related laws and regulations
• Excellent interpersonal and communication skills.
• Presentation skills necessary for quality subject matter.
Certifications/Licensure:
• Current California RN licensure or ability to obtain prior to start date
• Current Nevada RN licensure or ability to obtain within 6 months
• Certified Professional in Healthcare Quality (CPHQ) and/or Certified Joint Commission Professional (CJCP) and/or Certified Professional Patient Safety (CPPS) and/or Lean Six Sigma certification preferred.
• Current CPR/BLS certification by the American Heart Association (BLS for the Healthcare Provider)
Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• While performing the duties of this job, the employee is frequently required to walk, stand, sit, and talk or hear.
• The employee is occasionally required to use hands to finger, handle, feel or operate objects, tools, or controls; and reach with hands and arms.
• The employee is occasionally required to climb or balance; stoop, kneel, crouch, or crawl.
• Specific vision abilities required by this job include close vision, color vision, and the ability to adjust focus.
• The employee must occasionally lift and/or move up to 25 pounds.
Working Conditions
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Normal office environment. The noise level in the work environment is usually quiet to moderate while in the office.
• Occasional travel to various health system locations.
Essential Functions
1. Provides consistently exceptional care at all times.
2. Gathers, analyzes and creates reports related to quality and performance improvement data, which meets reporting agency requirements.
3. Supports the patient safety program with duties to include, but not limited to, managing event reports, promoting culture of safety, performing investigations, completing chart reviews and conducting root cause analysis processes.
4. Performs accreditation, regulatory and licensing functions which include continuous readiness activities, leading and/or coordinating surveys, and serve as liaison to CDPH, TJC, and any other regulatory agencies.
5. Prepares quality-related reports, supports committees and task groups.
6. Communicates with all levels of staff, management and medical staff regarding quality, patient safety and regulatory activities.
7. Leads performance improvement committees, prepares materials and presents information.
8. Serves as back-up to the Quality & Patient Safety Director.
9. Responds to the needs of the department by performing other duties, as necessary.
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