The Quality Coordinator has oversight over all quality and infection control related activities within the organization. Directs the efforts of all the performance improvement initiatives to ensure overall compliance with all regulatory standards including federal, state, CMS, and other agencies. The Quality Coordinator will assist the organization with continuous improvement in patient safety, preparation for regulatory surveys, regulatory reporting, quality improvement, and infection prevention projects. This position will have working knowledge of all core measures, performance improvement initiatives, quality dashboards, and patient safety activities. This position organizes and maintains systematic data collection, flow of information between departments, and reporting of information to required regulatory bodies. The quality coordinator position is a working nurse position. Selected candidate will cover one to two weekly nursing shifts on the hospital/ER department.
MINIMUM QUALIFICATION STANDARDS:
Education: Bachelor of Science in Nursing from an accredited institution
Licensure: Current and valid registered nurse license in Wyoming or multistate compact license from another state.
Current BLS, ACLS and PALS certification
Work Experience: Minimum 5 years’ experience in a clinical setting, preferably a hospital setting. 2 years Quality and Infection Prevention experience preferred.
Free from illegal use of drugs, and free from use and effects of use of drugs and alcohol in the workplace.
Free from any crimes of moral turpitude and crimes related to the neglect, mistreatment, or abuse of vulnerable individuals.
SKILLS AND KNOWLEDGE REQUIREMENTS:
Promote facility mission, vision, and values through daily work assignments; communications with co-workers, patients and families; practice accountability in work product; and advocate for higher quality of care.
Strong leadership ability with a focus on cultivating a team environment and motivating staff to produce and follow the facilities mission, values, and culture.
Adhere to and promote the continued willingness to re-evaluate procedures, policies, and structures to implement new systems of operation when changes are required to promote patient and facility health, safety and satisfaction.
Will engage every customer encounter with a high degree of service excellence focusing on creating a welcoming environment, anticipating customer needs, and providing excellent communication at all levels of the encounter to help the customer feel at ease, informed and confident in the care received.
Ability to work independently and manage multiple projects and activities simultaneously. Must be able to prioritize projects and handle change productively when assigned additional tasks/projects.
Conduct self in a professional, courteous manner with co-workers, staff, and the public in order to maintain a cooperative relationship among the healthcare teams. Always adhere to a philosophy and culture of teamwork and cooperation.
ESSENTIAL JOB FUNCTIONS:
Create, implement, and monitor quality and infection prevention programs; to include surveillance, data analysis, maintaining policies and procedures, and developing reports for administrators, medical staff, and the Board.
Participates in preventative screening programs (e.g., TB skin testing, influenza, hepatitis B, MMR, varicella, and other appropriate immunizations) and surveillance programs designed to identify and monitor risks to the employee’s health. Safely administers and appropriately documents on immunizations and TB skin tests given to Three Rivers Health employees.
Works closely with Clinical and Non-Clinical teams for improvement on key performance indicators, designs processes for new initiatives, services and other targets identified by Three Rivers Health leadership.
Serves as an internal consultant to administration, staff, and physicians in the areas of regulatory, process improvement, performance monitoring, and statistical analysis.
Focuses on better healthcare value and quality, including the improvement of clinical outcomes, patient experience, patient safety, costs, revenue, productivity, efficiency, employee and physician satisfaction, employee health, and process reliability.
Coordinate and manage Core Measures reporting to required federal and state regulatory bodies. Ensure the infection prevention and control procedures meet CMS, county and state, Association for Professionals in Infection Control and Epidemiology (APIC), and CDC regulations, standards, or guidelines.
Analyzes all assigned areas for opportunities of improvement and makes applicable recommendations for process, system, procedure, and operational changes to improve healthcare value and quality i.e.: Core Measures, Hospital Acquired Conditions, etc.
Monitors employee work-related illness and injury trends and assesses, develops, and implements strategies to prevent work-acquired injury or illness and expedite return to work.
Performs bloodborne pathogen and communicable disease exposure assessment, treatment and follow up. Notify the County and/or State Health Department of any reportable diseases, adhering to all internal county and state procedures.
Organize all Quality Management and Infection Prevention meetings, maintain minutes, and make recommendations to the committee based on best practice and current regulatory standards.
Participate in quality and infection prevent and control education of all employees during orientation and annually thereafter, including classes in infection prevention and control practices and employee health.
Will cover one to two nurse shifts per week in the hospital/emergency department adhering to the staff registered nurse essential job functions.
Perform other duties as assigned.
Observes all Federal, State, and local laws, rules, regulations and facility policies and procedures.
Able to carry out the essential functions of this job (with or without reasonable accommodation) without posing specific, current risk of substantial harm to health and safety of self and others.
NOTE: The essential functions are intended to describe the general content of and requirements of this position and are not intended to be an exhaustive statement of duties. Specific tasks, responsibilities and/or schedules may change as documented and outlined by the incumbent’s immediate manager.
PHYSICAL, PSYCHOLOGICAL AND ERGONOMIC REQUIREMENTS: