Job Summary
This position plans, coordinates, implements and evaluates facility and/or system-wide quality/performance improvements, patient safety programs, and/or coordinates compliance and regulatory programs for preparedness and accreditation requirements. The position works closely with system initiatives. All work processed by the incumbent is considered confidential and protected from discovery, pursuant to state statutes.
Essential Functions
Coordinates investigation, analysis, and responds to quality/patient safety issues, events, significant care issues or trends. Leads and/or facilitate root cause analysis, failure modes and effects analysis, and process improvement, working with multidisciplinary teams.
Develops and analyzes data for administrative and clinical decision making, as well as regulatory requirements. Coordinates implementation of data collection processes: provide analysis, summary, research and benchmarking. Prepares and present reports for appropriate facility, system, and other external agencies. Provides oversight to projects including data abstracting and data entry as appropriate.
Serves as a resource and leads and/or facilities task forces to plan, implement and coordinate facility activities to maximize service quality, effectiveness and efficiency. Collaborates with key stakeholders to evaluate, plan and implement process improvements and patient safety programs across the facility and/or system.
Supports implementation of facility quality and patient safety goals, policies, procedures, and activities designed to meet the requirements of regulatory and accrediting agencies such as JCAHO, CMS, DHS, and the peer review organizations.
Acts as consultant and educator in program development and special projects as determined by their supervisor.
Participates in implementation of evidence-based practices at the facility or system level.
May coordinate peer review activities for physicians and other healthcare providers and provide information for departmental improvement activities, credentialing, and reappointment.
In some roles, this position may supervise professional staff.
Minimum Qualifications
Requires Bachelors degree or equivalent in nursing or other healthcare related field and either an RN license in state worked OR a clinical background with current license/certification or equivalent experience.
Requires a proficiency level typically attained with 5 years acute care clinical experience.
Requires ability to perform complex statistical analysis and highly developed problem solving skills. Requires the ability to manage programs and projects. Requires demonstrated excellence in interpersonal and written communication skills.
Preferred Qualifications
Registered Nurse (RN) license preferred. Certified Professional in Healthcare Quality (CPHQ) certification is preferred. Experience with process improvement, regulatory/accreditation programs, data management, and analysis including graphic development and presentations is highly desirable
Additional related education and/or experience preferred.
