Quality Improvement Coordinator (RN)

Job Shift: Days

Job Type: Full Time

Leads Quality/Performance Improvement efforts to include: (a) tracks, trends, and analyzes data to identify and improve processes related to Quality/Performance Improvement programs; (b) makes  frequent rounds on nursing units and identifies areas of opportunity to improve patient outcomes; (c) develops reports, spreadsheets, charts, and presentations in support of Quality/Performance Improvement initiatives; and, (d) supports ongoing Joint Commission preparation including participation in the Joint Commission Survey Ready Team, unit-based audits, record reviews, and tracers in the coordination of and participation in mock surveys.

• Responsible to oversee and communicate quality data in a manner that promotes education, improvement and patient safety
• Assists with coordination of the ongoing Performance Improvement (PI) and peer review activities of medical staff
• Responsible for directing and reviewing physician quality improvement evaluations specifically ongoing Professional Practice Evaluations
• Responsible for the general oversight and maintenance of the organization’s system-wide measurement systems; this may include but not limited to, data entry, aggregation and maintenance of the monthly reports for PI Committee, data entry into facility’s performance scorecards and dashboards, as well as the data integrity of the measures for the facility-specific and home office reports
• Active participation in an investigation of episodes that require intensive review 
• Objectively and systematically collects dates, measures and assesses the quality and appropriateness of patient care
• Uses pre-established indicators/criteria, occurrence/variance reports in performing concurrent/retrospective reviews
• Reviews specific procedures/diagnoses for appropriateness, outcome and resource utilization
• Maintains accurate and complete documentation of reviews in the tracking system, peer review reports and files
• Attends medical staff meetings, prepares and reports PI and peer review activities as scheduled; assists in preparation of letter to physicians as a result of peer review in collaboration with the Quality Manager/Director.
• Facilitates PI activities of departments to assure quality and appropriateness of patient care, services and utilization of resources
• Actively maintains current knowledge of regulatory standards and requirements; provides assistance and contributes to detailed investigations as needed
• Participates in interdisciplinary teams, task forces, committees or PI groups as needed; uses statistical tools for identification of trends, patterns and variations in care, services, etc
• Actively assists with regulatory survey preparation as needed
• Actively participates in and/or coordinates thorough and in-depth review of significant patient care issues as directed; serves as a resource for departments to assist with identification and resolution of quality and/or patient safety issues
• Assists with staff education and department implementation of Performance Improvement activities as required by regulatory agencies 
  Performance Improvement:
  • Identifies opportunities for improvement based on observations, process and outcome indicators, and other findings;
  • Acts as an agent of change and participates in the change process;
  • Conducts rounding, audits, and tracers to provide related education to staff, patients and visitors
  • Assists in the facilitation of the control improvement activities;
  • Participates in the organization’s multidisciplinary improvement strategies;
  • Participates in the process of continuing education by having oversight of the Policy Manger System
• Maintains a safe environment and responds with confidence and adapts to rapid changing conditions and emergent situations
• Coordinates and collaborates with multidisciplinary team members in the planning and management of patient care to meet patient needs
• Responds to the unique needs of patients and families coping with unanticipated treatment, quality of life, and end-of-life decisions
• Monitors and allocates patient care services, recognizing the fiduciary role of nurses working in a resource intensive environment
• Maintains and promotes professional standards with a constructive, proactive approach and development by participating in Performance Improvement needs, in-services, committees and staff meetings
• Serves as a role model for compassionate care and service excellence and commits to Studer Principles and “must haves”·    Facilitates problem resolution and team collaboration among staff by displaying a positive attitude within department and other colleagues to contribute to customer service program, and assists leadership by mentoring and coaching staff as well as accepting to orient new staff and act as a preceptor
• Serves as a resource, anticipates the needs of others and offers positive suggestions and productive feedback
• Facilitates throughput within the facility, proactively managing admissions, discharges and transfers including the ability to prioritize to maximize efficiency and recognize acuity levels
• Effectively manages hand-offs at shift change and between department and facilities; utilizes documentation tools for hand-offs as required
• Abides by regulatory agencies standards and provides every patient the defined standard of care (ie; core measures, chest pain protocol) 
• Utilizes resources efficiently and effectively by demonstrating independence and resourcefulness 
• Adheres to Tenet Standard of Conduct as well as hospital policies and procedures
• Attends safety training programs and demonstrates adherence to proper hospital exposure procedures
• Actively pursues personal and professional development including a constructive approach with colleagues
• Addresses patient population-specific including an inclusive culture
• Performs all responsibilities/duties required by the specific unit as defined in the scope of service and demonstrates effective unit specific skills
• Maintains required competencies, certifications, online education and assures orientation to floating unit is completed
• Balances team and individual responsibilities and is objective and open to others' views
• Demonstrates dependability/flexibility and assumes other duties and responsibilities as assigned
• Performs all responsibilities/duties required by specific unit/department
   

MINIMUM EDUCATION:  

Required: Bachelor's degree in patient care related field 
 

MINIMUM EXPERIENCE:   

• Required:  3 years of experience in healthcare or quality management

REQUIRED LICENSES/CERTIFICATIONS:  

• Current RN Licensure in the State of Texas or Compact State  
• Current Healthcare Provider Basic Life Support (American Red Cross or American Heart Association)
• if American Red Cross, must obtain American Heart Association within 60-days of hire
• Preferred; CPHQ or HACP-CMS

REQUIRED SKILLS, KNOWLEDGE, and ABILITIES: 

• Demonstrated proficiency and competency in Quality Improvement 
• Has effective interpersonal and communication skills and ability to serve as a role model and advocate for the profession
• Ability to use hospital equipment and has proficient computer skills 
• Demonstrates professionalism and aligns with leadership values

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