Quality & Safety Coordinator

Jchealthandlife; Nebraska; Presencial; USD 70 000 - 100 000; Tempo integral

Resumo da oferta

Jefferson Community Health & Life is seeking a qualified Quality & Safety Coordinator to lead organization-wide QAPI, infection prevention, employee health, risk management, and patient safety initiatives. This role collaborates with executive leadership, medical staff, and department managers to improve patient outcomes and reduce organizational risk.

The position requires RN licensure in Nebraska and a commitment to regulatory compliance, with preferred BSN and certifications in CIC and CPHQ.

Qualificações

• Graduate of an accredited professional nursing program is required.
• Bachelor's degree in nursing (BSN) preferred.
• Minimum of three years of clinical nursing experience; five years preferred.
• Experience in healthcare quality improvement, infection prevention, employee health, or risk management preferred.

Responsabilidades

• Coordinates and manages organization-wide QAPI program in accordance with CMS requirements.
• Coordinates development, implementation, monitoring, and evaluation of annual quality improvement plan.
• Collects, abstracts, analyzes, and reports inpatient and outpatient quality measures.
• Coordinates quality reporting, including CMS measures, MBQIP, eCQMs, and other programs.
• Monitors quality indicators and outcomes to identify improvement opportunities.
• Facilitates Quality Council meetings and prepares reports for leadership and Board.

Formação académica

Nursing degree (RN) required

BSN preferred

CIC certification preferred

CPHQ certification preferred

Descrição da oferta de emprego

If you are unable to complete this application due to a disability, contact this employer to ask for an accommodation or an alternative application process.

Quality & Safety Coordinator

Nursing Admin Full Time Professional Fairbury, NE, US 1 Attachments

6 days ago Requisition ID: 1340

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