Benefits: - Health insurance
- Paid time off
- Vision insurance
- 401(k)
- 401(k) matching
- Dental insurance
JOB SUMMARYMaintains ongoing status of quality assessment and performance improvement activities. Reviews and analyzes all systems. Integrates quality assessment and performance improvement activities with the risk management program to minimize the facility's risk of financial loss due to claims or litigation. Serves as the Management Representative for the Quality Management System, and Clinical Safety Officer.
Reports To: Chief Nursing Officer
Classification: Exempt
Supervises: Quality Risk Coordinator, Nurse Educator
QUALIFICATIONSBachelor's degree in Nursing (BSN) required. Current Registered Nurse (RN) license in the state of Louisiana or compact state. Experience in risk management, quality assessment, and performance improvement required: Certified Professional in Healthcare Quality (CPHQ) certification preferred. Minimum of five years of experience required.
OCCUPATIONAL EXPOSURECategory I exposure to bloodborne pathogens, frequent exposure to chemical hazards and may encounter radiation hazards.
RESPONSIBILITIES - Quality Assessment & Performance Improvement Program1. Serves as the Management Representative for the Quality Management System. Is responsible for the process for internal reviews (internal audits) and management reviews to ensure the corrective and preventive actions are carried out and are measured for effectiveness.
2. Provide oversight for the facility education program with design, implementation and evaluation for effective outcomes.
2.1 Provide leadership and oversight for orientation, onboarding, annual competencies, mandatory education, continuing education, and quality improvement education for all clinical and non-clinical personnel.
2.2 Provide administrative oversight for the facility's education program, including educational activities for employees, medical staff, advanced practice providers, residents,
nursing students, scrub technician students, LSUA nursing and allied health students, contracted personnel, vendors, and other healthcare learners. Ensure educational programs are effectively designed, implemented, evaluated, and maintained to support organizational goals and regulatory compliance.
2.3 Collaborate with department leaders, physicians, educational institutions, and the Education Coordinator to ensure educational programs comply with DNV, CMS, OSHA, CDC, and organizational standards while supporting competency validation, patient safety, infection prevention, emergency preparedness, and quality improvement initiatives.
2.4 Provide executive oversight of student clinical experiences, affiliation agreements, competency requirements, and educational partnerships to ensure compliance with regulatory, accreditation, and organizational requirements.
2.5 Evaluate the effectiveness of the facility education program through competency validation, regulatory outcomes, quality metrics, survey readiness, and performance improvement data, implementing corrective actions and strategic improvements as indicated.
3. Accepts accountability for the progress and development of the Organization's adopted Quality Assessment and Performance Improvement Program (QAPI).
3.1 Performs according to established quality assessment and performance improvement policies and procedures.
3.2 Supports risk management and participates in programs directed to patient and employee safety.
3.3 Objectively evaluates suggestions or grievances to identify means to improve standards of performance.
3.4 Establishes systems to identify resources required for support of the Quality Assessment and Performance Improvement Program, to monitor resource disbursement and to evaluate resource use and requirements.
3.5 Submits resource requests to the Medical Executive Committee by preparing and submitting reports that identify and project resources required for support of the Quality Assessment and Performance Improvement Program.
3.6 Successfully contributes to the quality improvement process and identifies role and contributions upon supervisor's request.
4. Accepts accountability for the progress and development of the Organization's Risk Management Program.
4.1 Maintains and implements a variance reporting system for the Facility
4.2 Receives and reviews all Variance Reports generated by personnel at the Facility before they are presented to the Administrator and/or CNO.
4.3 Works with the Administrator/CNO in investigating and analyzing all variances and all actual and actual and potential risks at the Facility.
4.4 Takes steps to ascertain that risks are minimized through follow-up and action plans when developed.
4.5 Manages compliance with all regulatory, external and internal surveys and subsequent recommendations or action plans.
4.6 Integrates risk management data with the Facility's Quality Assessment and Performance Improvement and Medical Executive Committee activities.
4.7 Evaluates variance patterns and trends.
4.8 Prepares reports and summarizes on all risk management findings to the QAPI Committee on an ongoing basis.
4.9 Reviews and assesses risks and assures development of corrective action plans. (PDCA)
4.10 Directly provides risk management education to staff during initial orientation and when needed
4.11 Works on all potentially compensable events or claims if directed, regarding any professional liability situation or potential claim.
4.12 Maintains variance, risk management and legal files in a confidential and appropriate manner.
4.13 Reviews reports of product problems (e.g., drug or devices recalls) with Material Management; assesses problem area; and resolves the situation.
4.14 Coordinates and oversees the Facility's compliance with Safe Medical Device reporting and tracking.
4.15 Participates in evaluating/implementing Hazard Surveillance risk assessments and risk reduction activities along with other designated Facility staff.
4.16 Serves as a resource person on Risk Management to Facility staff and members of the medical staff.
4.17 Works with the Facility Chief Medical Officer or other physicians in regard to quality and risk management events and activities.
5. Communicates effectively with patients, visitors, physicians and co-workers.
5.1 Interactions are respectful and courteous
5.2 Communicates effectively and professionally.
5.3 Assures understanding of all assigned risk follow-up activities by all personnel involved.
6. Maintains and promotes professional competence by participating in and organizing continuing education and other learning experiences.
6.1 Organizes and participates in committees, conferences and quality improvement activities
6.2 Maintains membership in relevant professional organizations
6.3 Objectively evaluates suggestions and criticism and attempts to improve performance or seeks further guidance, as needed.
6.4 Attends annual Quality/Risk & IC Management conference to maintain current knowledge of trends and reporting guidelines.
7. Maintain an effective, comprehensive Quality Assessment and Performance Improvement Program.
7.1 Establishes standards and criteria for the program and enforces quality improvement policies.
7.2 Regular reviews of CoPs and DNV standards to provide direction and serve as gatekeeper for regulatory and quality reporting updates. As such, educates all department managers of need policy changes and implementation of current standards.
7.3 Reviews and assists in establishing indicators with a representative from each dept and trains patient care personnel regarding the indicators used in assessment.
7.4 Initiates in-services for all Facility personnel and Medical Staff regarding the monitoring systems and use of evaluation thresholds in the QAPI Program.
7.5 Prepares reports for QAPI Program.
7.6 Develops recordkeeping and reporting functions and maintains appropriate files.
7.7 Evaluates program and recommends appropriate revisions.
8. Develops and recommends effective data collection and evaluation systems to identify opportunities to improve patient care.
8.1 Establishes systems to collect and organize data used in monitoring and to continually assess the success of problem resolution activities.
8.2 Assists personnel and medical staff in identifying aspects of care that are high volume, high risk and problem prone.
8.3 Maintains Quality Dashboard.
8.4 Completes and maintains records of problem status for follow-up and distributes corrective action reminder report.
9. Participates in the Quality Assessment and Performance Improvement Committee and assists in the dissemination of information to appropriate areas.
9.1 Submits timely, accurate reports to the QAPI Committee to Governing Body.
9.2 Provides quality assessment and performance improvement information to departments/services, as necessary.
10. Coordination of benchmark data reporting on specified measures.
11. Comply with facility Standards of Behavior and complete all required education assignments within the designated timeline
PHYSICAL DEMANDS1. 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.
2. While performing the duties of this job the employee is frequently required to sit, converse, and listen; use hands to touch, handle, or feel objects, tools or controls; and to reach with hands and arms. Specific vision abilities required by this job include close vision and the ability to adjust focus.
3. The employee must be able to lift and/or carry over 20 pounds on a regular basis and be able to push/pull over 25 pounds on a regular basis.
4. The employee must be able to stand and/or walk at least two hours per day.
WORK ENVIRONMENT1. 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.
Central Louisiana Surgical HospitalA Patient-Focused, Physician-Owned Hospital
The Central Louisiana Surgical Hospital provides specialized care for patients with specific, non-critical and non-emergent surgical admissions. The ultimate goal of the facility is to assist patients throughout their stay to a successful recovery, by providing a setting and care that is a more effective delivery of health care. This is accomplished by providing a comfortable home-like setting, in which a caring professional staff works to insure the highest level of patient care in a more cost-effective setting. Family support and involvement is promoted and encourage as well. This supports the patient's self-image as "other-wise healthy" and facilitates a speedier return to the community, reducing health care costs and strengthening the economy at large.
The surgical hospital offers procedures for the following specialties: ENT, gastroenterology, general surgery, gynecology, neurosurgery, ophthalmology, oral surgery, orthopedics, pain management, plastic surgery, podiatry and urology.
In addition to surgical services, Central Louisiana Surgical Hospital has an imaging department comprised of MRI, CT, general radiology and ultrasound, as well as laboratory, pharmacy and dietary services.
The facility provides a full-time staff of registered nurses, licensed practical nurses, technicians and other ancillary personnel for patient care in the perioperative setting. In addition, the facility has available necessary equipment and trained personnel for handling unforeseeable emergencies.
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