Job 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.
AVMC Values: All AVMC employees will effectively demonstrate these values:
-
Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
-
Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
-
Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
-
Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
-
Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
-
Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
-
Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.
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
AVMC Conduct/Compliance Expectations:
- Ability to adhere with AVMC Attendance and Punctuality Policy.
- Ability to adhere with AVMC Leaves of Absence Policy.
- Ability to adhere with AVMC Paid Time Off (PTO) Policy.
- Ability to adhere to the department dress code.
- Ability to organize work and establish priorities.
- Ability to expand on own initiative in performance of duties.
- Skill and ability to follow the telephone etiquette/standards.
- Ability to function effectively under pressure and meet time parameters.
- Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.
- Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.
- Ability to maintain the confidentiality of patient, hospital and department information.
- Ability to adhere to safety rules and regulations.
- Safely and effectively uses all equipment necessary to carry out duties.
- Ability to interpret and function under hospital and department policies and procedures.
- Conforms with required and appropriate accreditation and regulatory requirements.
- Conforms with and supports hospital quality assurance and improvement guidelines.
- Ability to participate effectively in department and hospital staff education.
- Display a willingness to work as a team player.
- Ability to give and support the highest level of patient/customer satisfaction at all times.
- Supports and adheres to the values and mission statement established by the AVMC Board of Directors.
- Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
- Ability to follow the Code of Conduct.
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.
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
