Jefferson Community Health & Life is looking for a Quality & Safety Coordinator.
Hours: M-F, 40 hours per week. Non-exempt
POSITION SUMMARY:
The Quality & Safety Coordinator is responsible for coordinating, implementing, monitoring, and evaluating Jefferson Community Health & Life's organization-wide Quality Assessment and Performance Improvement (QAPI), Infection Prevention and Control, Employee Health, Risk Management, and Patient Safety programs.
This position manages the coordination of quality data collection, analysis, and reporting; facilitates performance improvement initiatives; investigates patient safety events; and promotes compliance with applicable federal and state regulations.
The coordinator works collaboratively with executive leadership, medical staff, department managers, Human Resources, and other healthcare professionals to improve patient outcomes, reduce organizational risks, promote employee and patient safety, and support a culture of continuous improvement throughout JCH&L.
QUALIFICATIONS:
- Education and/or Experience
- Graduate of an accredited professional nursing program required.
- Bachelor’s degree in nursing (BSN) preferred.
- Minimum of three years of clinical nursing experience required; five years preferred.
- Experience in healthcare quality improvement, infection prevention, employee health, or risk management preferred.
- Experience in a Critical Access Hospital or rural healthcare setting preferred.
- Knowledge of CMS Conditions of Participation and applicable healthcare regulatory requirements preferred.
- Licensure and Certification
- Currently unrestricted Registered Nurse (RN) license in Nebraska or a valid multistate RN license authorizing practice in Nebraska required.
- Certification in Infection Control (CIC) preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
- Must complete required infection prevention training and maintain appropriate competencies.
- Must maintain clinical competencies necessary to administer immunizations, assess occupational exposures, and perform assigned employee health responsibilities within the RN scope of practice.
ESSENTIAL JO DUTIES AND RESPONSIBILITIES:
Quality Assurance and Performance Improvement (QAPI)
- Coordinates and manages the organization-wide QAPI program in accordance with applicable CMS Conditions of Participation and other regulatory requirements.
- Coordinates the development, implementation, monitoring, and evaluation of the organization's annual quality improvement plan.
- Collects, abstracts, validates, analyzes, and reports inpatient and outpatient quality measures.
- Coordinates required quality reporting, including applicable CMS measures, Medicare Beneficiary Quality Improvement Project (MBQIP), electronic clinical quality measures (eCQMs), Nebraska Hospital Association initiatives, and other reporting programs.
- Monitors quality indicators, trends, and outcomes to identify opportunities for improvement.
- Coordinates and facilitates Quality Council meetings, including agendas, minutes, reports, and follow-up activities.
- Prepares and presents quality reports to executive leadership, Quality Council, and the Board of Directors.
- Coordinates quality reporting to the medical staff in collaboration with the Chief Medical Officer.
- Works collaboratively with Health Information Services to coordinate and support the organization’s medical staff peer review process, including appropriate documentation, tracking, and follow-up while maintaining confidentiality.
- Works with department managers to establish performance improvement goals and monitor progress.
- Facilitates performance improvement initiatives utilizing recognized methodologies such as Plan-Do-Study-Act (PDSA) and root cause analysis.
- Tracks corrective action plans and evaluates the effectiveness of implemented improvements.
- Provides education and guidance to department managers and employees regarding quality improvement initiatives.
- Maintains documentation of QAPI activities, performance measures, and improvement outcomes.
Infection Prevention and Control
- Serves as the organization's designated Infection Preventionist, subject to applicable qualifications and training requirements.
- Coordinates, implements, monitors, and evaluates the organization-wide infection prevention and control program.
- Conducts surveillance of healthcare-associated infections and communicable diseases.
- Investigates potential outbreaks, infection trends, and exposures, and coordinates appropriate interventions.
- Collects, analyzes, and reports infection prevention data to applicable regulatory agencies, including the National Healthcare Safety Network (NHSN) and Nebraska Department of Health and Human Services.
- Develops, reviews, and recommends updates to infection prevention policies and procedures.
- Conducts infection prevention rounds, audits, and assessments to identify potential risks and areas for improvement.
- Coordinates Infection Control Committee activities, including meeting preparation, documentation, and follow-up.
- Provides infection prevention education during new employee orientation and ongoing employee training.
- Collaborates with clinical departments, Environmental Services, Laboratory, Surgery, and other departments to promote infection prevention practices.
- Serves as a resource to employees, medical staff, and department managers regarding infection prevention and control.
- Maintains knowledge of current infection prevention standards, regulatory requirements, and evidence-based practices.
Employee Health
- Coordinates and maintains the organization's employee health program.
- Conducts employee health assessments and makes appropriate nursing judgments regarding employee health needs, occupational exposures, and required follow-up.
- Conducts or coordinates required pre-employment health screenings and assessments.
- Reviews employee immunization histories and determines applicable immunization and screening requirements based on job responsibilities and organizational policies.
- Administers employee immunizations in accordance with approved protocols, provider orders when required, and applicable nursing practice standards.
- Coordinates employee vaccinations, tuberculosis screening, and other required employee health services.
- Maintains accurate and confidential employee health records.
- Monitors compliance with required employee health screenings, immunizations, and other occupational health requirements.
- Evaluates occupational exposures, including bloodborne pathogens and communicable diseases, and coordinates appropriate testing, treatment referrals, and follow-up.
- Assists with exposure investigations and maintains appropriate documentation.
- Collaborates with Occupational Health regarding respiratory protection requirements, including medical evaluations and fit testing.
- Provides employee health education related to infection prevention, occupational exposures, and communicable disease prevention.
- Collaborates with Human Resources and appropriate healthcare providers regarding medical clearances, fitness-for-duty, and return-to-work matters while maintaining confidentiality of employee medical information.
Risk Management and Patient Safety
- Coordinates the organization's risk management and patient safety activities.
- Reviews and monitors of safety events, incidents, adverse events, and near misses reported through SQSS.
- Investigate reported incidents, gather relevant facts, reviews documentation, and communicates findings to appropriate leadership.
- Identifies trends involving patient falls, medication errors, treatment delays, transfers, and other patient safety concerns.
- Coordinates root cause analyses, focused reviews, and other investigations as appropriate.
- Collaborate with department managers to identify contributing factors and develop corrective action plans.
- Monitors corrective actions and follows up to evaluate effectiveness.
- Identifies potential patient safety and organizational risks and recommends preventive measures.
- Promotes timely reporting of incidents, near misses, and safety concerns.
- Communicates significant patient safety concerns or potential liability issues to the COO and appropriate executive leadership.
- Assists with documentation and fact-finding related to potential claims or legal matters as directed by the COO.
- Maintains confidentiality of incident investigations and risk management information.
Patient Satisfaction and Experience
- Monitors patient satisfaction results, comments, and concerns through NRC Health and other patient feedback systems.
- Reviews patient feedback to identify trends, concerns, and opportunities for improvement.
- Collaborates with executive leadership and department managers regarding patient satisfaction concerns and appropriate follow-up.
- Refers department-specific concerns to the appropriate manager for investigation and response.
- Assists with follow-up and tracking to ensure patient concerns are appropriately addressed.
- Identifies patient satisfaction trends and recommends opportunities for service improvement.
- Incorporates patient experience findings into quality improvement initiatives as appropriate.
- Assists with patient complaint and grievance processes in accordance with organizational policies and applicable regulatory requirements.
Regulatory Compliance and Survey Readiness
- Monitors applicable federal and state regulations related to quality, infection prevention, employee health, risk management, and patient safety.
- Assists with maintaining organizational readiness for regulatory surveys and inspections.
- Coordinates preparation of required documentation and reports within assigned areas of responsibility.
- Collaborate with department managers to identify and address regulatory compliance concerns.
- Reviews and recommends updates to policies and procedures based on regulatory changes and recognized standards.
- Assists with the development, implementation, and monitoring of corrective action plans.
- Participates in regulatory surveys, inspections, and follow-up activities as appropriate.
- Provides education and guidance to employees and managers regarding applicable regulatory requirements.
- Communicates significant compliance concerns to the COO and appropriate leadership.
Education, Communication, and Organizational Collaboration
- Provides education and training related to quality improvement, infection prevention, employee health, patient safety, and risk management.
- Serves as a resource to department managers, medical staff, and employees regarding assigned programs.
- Coordinates and participates in applicable organizational committees, including Quality Council, Infection Control, and Safety.
- Collaborate with department managers to implement and monitor quality and safety initiatives.
- Promotes a culture of patient safety, accountability, and continuous improvement.
- Maintains effective communication with executive leadership regarding program activities, performance measures, and identified concerns.
- Attends Administrative Team and other leadership meetings when requested to present reports or information.
- Maintains professional knowledge through continuing education, professional organizations, and regulatory updates.
Fiscal Accountability and Program Management
- Assists with the development and monitoring of budgets related to assigned programs.
- Identifies opportunities to improve efficiency and reduce unnecessary costs.
- Evaluates supplies, equipment, and resources related to infection prevention, employee health, and quality initiatives.
- Recommends appropriate resources and improvements to the COO.
- Maintains accurate program records, reports, and documentation.
Professional Development and Performance Improvement
- Participates in required continuing education and professional development activities.
- Maintains current knowledge of healthcare quality, infection prevention, employee health, and risk management practices.
- Participates in applicable professional organizations and educational opportunities.
- Demonstrates professional accountability, effective communication, and commitment to organizational improvement.
- Supports JCH&L's mission, vision, values, and service excellence standards.
Scope of Authority and Responsibility
- The Quality & Safety Coordinator independently coordinates assigned programs and is responsible for timely reporting, investigations, monitoring, and recommendations.
- The coordinator does not have direct supervisory authority over department managers or employees. Department managers retain responsibility for implementing operational changes within their departments.
- The COO provides administrative oversight and retains primary responsibility for legal matters, liability claims, and organizational decisions requiring executive approval.
Performs other duties as assigned