DescriptionJob Objective:Under the direction of the Manager of Quality and Clinical Safety, this position is responsible for coordinating quality clinical safety activities, as part of the Performance Improvement (PI)/Quality Management (QM) and Clinical Safety (CS)/Risk Management programs (RM). Activities include patient care processes, outcomes, organizational functions, data collection, and regulatory preparation.
Duties and Responsibilities:- Participates in the design and development of multidisciplinary and interdisciplinary processes to support and address the situation or issue such as Quality Improvement (QI) initiatives or Teams.
- Facilitates multidisciplinary teams and provides direction to enhance effectiveness.
- Contributes to the development and continuous improvement of organizational systems that support the performance improvement and risk management programs.
- Completes focus review or other quality studies and reports for presentation to QM, Medical Staff and/or other Hospital Committee meetings.
- Fosters organization systems that support implementation of the CS Plans and RM Plans.
- Supports clinical safety activities and functions.
- Develops statistical reports and conducts data analysis as part of the QI cycle.
- Acts as a member and representative for organization committees, including Medical Staff Department or Performance subcommittees, as assigned.
- Reviews and analyzes sentinel events/near misses with appropriate medical and/or hospital staff.
- Conducts case summaries, analysis, and preparation of timelines and succinct written reports for QM or RM.
- Coordinates and conducts intense analysis and ensures timely follow-up of activities.
- Assists and supports the peer review process including Ongoing or Focused Professional Practice Evaluation studies.
- Uses the results of evaluation analyses to make or recommend process or structural changes, including policy, procedure, or protocol documentation, as appropriate.
- Implements initiatives to evaluate the need for change.
- Contributes to the development and continuous improvement of organizational systems that support the planning process
- Analyzes and trends reports from the Patient Safety Electronic Event Reporting program. Collaborates with staff to complete follow-up investigation as needed.
- Coordinates follow-up responses to 3rd parties and as back-up to the Director for patient grievances and other communication with Patient Guest Relations.
- Supports the Regulatory Coordinator in the direction of Clinical Safety functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff with emphasis on clinical safety.
- Assists the director in providing staff education on QM, CS, or RM topics.
- Works with Regulatory Coordinator in the direction of QM and RM functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff.
- Manages, aggregates, and reports information derived from the hospital-wide event reporting system and/or other sources.
- Confidentiality
- Refrains from disclosing confidential information acquired in the course of work except when authorized, unless legally obligated to do so.
- Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties
- Refuses any gift, favor or hospitality that would influence or would appear to influence actions
Non-Essential Duties:• Other duties as assigned by the Director of Quality Management, Clinical Safety and Infection Control
Knowledge, Skills and Abilities: Knowledge• Current knowledge of QM and CS principles.
• Knowledge of Regulatory and Accrediting bodies such as CMS, JC, State Department of Health and insurance providers.
• Maintains an appropriate level of professional competence by ongoing development of knowledge and skills.
Skills• Strong communication skills to include group presentations
• Skill and ability to follow the established Customer Service Expectations and Standards
• Computer skills to include data entry. Working knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, and Word)
• Demonstrated expertise in systems analysis and management skills at a minimum of an assistant director level
Abilities• Ability to work effectively with hospital and medical staff professionals
• Ability to handle patient care concerns with objectivity and professionalism
• Uses current research findings and other evidence to expand knowledge, enhance role performance, and increase knowledge of professional issues.
Education and Experience:Education• BSN required to be completed within three years or 5 years of experience in lieu of degree.
• MSN or MS equivalent preferred.
• Certification in either Quality or Risk Management desired.
Experience• Three years' Clinical experience in Acute Hospital preferred.
• Experience or training in statistical methodologies and data analysis preferred
Required Licensure and/or Certifications:• Current California Registered Nursing or LVN license
Physical Requirements and Working Conditions:- Work is often performed under stressful, emotional and physical conditions for the office environment
- Work is performed both in an office and nursing unit environment
- Must be able to make walking rounds and conduct record reviews and/or speak with patient/family as needed throughout the hospital
A detailed description of the physical requirements of this job is maintained in the Employee Health Department.
RequirementsEducation and Experience:Education• BSN required to be completed within three years or 5 years of experience in lieu of degree.
• MSN or MS equivalent preferred.
• Certification in either Quality or Risk Management desired.
Experience• Three years' Clinical experience in Acute Hospital preferred.
• Experience or training in statistical methodologies and data analysis preferred
Required Licensure and/or Certifications:• Current California Registered Nursing or LVN license
