BWH QI Coordinator

Position Summary:

The QI Coordinator works with the CNO, Director of Support Services, COO, Department Heads, and the Executive Assistant to the CEO /CMO to assist with QI functions and administrative tasks and completes these tasks accurately and in a timely manner.

Essential Job Functions:

• Organizes all activity relating to the Quality Improvement Committee including the data collection processes for chart audits for The Joint Commission Oryx project and plans of action, agenda and minutes. 
• Tallies patient satisfaction surveys monthly for hospital and outpatient programs.  
• Ensures that CMS QNet report is reviewed by the QIC Committee.   
• Facilitates a FMEA for the organization as required as directed by the CNO.  
• Reviews and tracks incident reports for the CNO to help the organization to identify potential trending occurrences as needed.  
• Serves as administrator for the organization's access to Press Ganey and ensures annual completion of facility profile form.
• Assists the QIC members in preparing QI reports, prepares spreadsheets to display data as requested.
• Distributes and tallies annually hospital wide staff safety survey.
• Maintains documents for upcoming accreditation surveys from the Joint Commission and assists in completion of measures of success post survey for Support Services Department & Pharmacy Therapeutics Committee.
• Works with the Chief Nursing Officer to assure that the QI Plan is continually documented, updated, and revised as necessary.
• Works with the Director of Support Services Department on projects as needed including organizing paperwork and preparing for Safety/EOC Committee.  Schedules and tracks inspections for the Building Maintenance Program at both the Brookline and Woburn sites.  Maintains documentation of the Building Maintenance Program for survey inspections including a monthly status report to the Director of Support Services.
• Ensures recall notices are reviewed by appropriate staff to minimize use of recalled equipment or food. Maintains documentation of recall notices. 
• Maintains the safety data manual and provides company vendor with changes of products to ensure accurate information is accessible to staff under the direction of the Director of Support Services.
• Organizes the Safety/EOC Committee meeting minutes, agendas and action plan.
• Organizes the P&T Committee meeting minutes, agendas and action plan.
• Maintains Bournewood’s pager distribution and pager maintenance for the Director of Support Services including pager invoice review; and assists with pager usage instruction as called upon.  
• Provides back up administrative support in absence of Executive Assistant to the CEO/Medical Staff to include taking minutes, distributing mail, and DOC schedules.
• Completes special projects or any other duties as assigned by the Executive Management Team.
• Takes employee photographs at orientation and maintains employee photo database to keep current. 
• Maintains Affiliation Agreements for Care for the Chief Operating Officer.
• Trains new and covering staff as needed.

Education & Experience:

• Graduate of accredited college/university or business school.
• Minimum three years' experience in comparable position.