Overview

Job Summary:

Provide guidance and support for quality improvement and TJC readiness.

 

Also shares the responsibility for retrospective review, abstraction and data submission needed to assure hospital-wide compliance with inpatient quality reporting requirements, inpatient psychiatric reporting and outpatient. The role involves extensive work getting information from Meditech, and chart review as well as direct communication with clinicians. It includes data entry, maintenance of spreadsheets and reports, and participation in quality improvement activities as assigned. 

 

The coordinator must be able to develop and maintain effective interpersonal relations, maintain confidentiality of all data, information, and activities, and be able to perform detailed, concentrated work with limited supervision.

 

The coordinator must be flexible and willing to adapt to changes in workload/assignments depending on the organization’s needs.

Responsibilities

Key Responsibilities / Essential Functions

1.         Serves as a resource to Department Director, staff and community.

2.         Analyzes data to identify opportunities for process improvement.

3.         Functions as a consultant to staff for solving challenging utilization issues.

4.         Maintains and disseminates requirements for TJC.

5.         Serves as the liaison between Directors to standardize the quality boards..

6.         Facilitates education of mandated requirements for TJC.

7.         Conducts monthly audits as needed.

8.         Assists with special projects as assigned by the Department Director.

9.         Takes action to assist with the improvement of Units HCAPHS Score

10.        Assist in development of criteria and indicators for Quality Improvement activities as well    as implementation and follow up.

11.        Assure effective communication and coordination for Quality Initiatives across Departments.

12.        Assist in leading change regarding quality of nursing care delivered.

13.        Participates in leadership activities such as committees, professional organizations, publishing, teaching, and research.

14.        Remain current with Quality Improvement trends and TJC changes.

15.        Attends Units Staff Meetings and serves as a resource.

16.        Assumes other duties as assigned.

 

 

Qualifications

Minimum Knowledge, Skills, Experience Required:

Graduate of an accredited school of nursing: BSN Preferred

Minimum 3 years nursing experience in an acute care facility; knowledge of hospital systems and procedures preferred. Experience in Quality, Case Management and/or Lean Six Sigma is plus.

Moderate to advanced computer skills, including the use of Microsoft Office (Word, Excel, PowerPoint). Ability to develop, maintain spreadsheets and databases as required to perform quality outcome duties.

Able to communicate effectively both verbally and in writing.

 

Able to comprehend complex clinical data.

 

 Able to organize, prioritize and manage time efficiently to meet deadlines.

License/Certification:Required: Current Alabama RN License