Quality Risk Management - Clinical Quality Improvement Coordinator

This is a full time (0.8 - 1.0 Status) day shift Clinical Quality Improvement Coordinator position in the Quality Risk Management department.

POSITION SUMMARY

Under the direction and supervision of the Director of Quality Risk Management, the Harms Prevention Quality RN Coordinator is responsible for reducing the number of preventable and other harms attributed to the facility. This is completed through a systematic process of prospective chart review, direct collaboration with the patient care team, and the facilitation of performance improvement initiatives identified as the best practices for harm prevention.

Responsibilities shall be discharged in such a manner as to support the goals and objectives of the Medical Center’s Quality Improvement and patient safety program and in keeping with Mission, Philosophy, and values of the organization.

PRIMARY (ESSENTIAL) DUTIES

1. Promote Quality and Patient Safety
   1. Retrospective review of assigned harms to identify trends and opportunities for improvement.
   2. Maintain a working knowledge of the harms categories through researching the CMS and other source specifications.
   3. Research of evidence-based practices and presentation to Performance Improvement teams for review and consideration.
   4. In conjunction with peers and the Infection Preventionist will provide cross coverage to ensure that Interdisciplinary Rounds and Unit Based Rounds are sufficiently covered daily to ensure early identification of potential opportunities for preventing harms.
   5. Analyze and collate data for review by the PSCQ.
   6. Use of the PI toolkits to facilitate and participate on PI Teams to improve processes related to Harms reduction strategies including accurate agendas, minutes, and follow up.
   7. Review of processes and/or documentation to ensure adherence to quality & safety regulations, standards, and policies and procedures.
   8. Evaluate risk of harm for patients and communicate to the care team to ensure early and proper implementation of appropriate interventions.
   9. Work with the Director of Quality Risk Management and the Data Analyst Specialist to ensure data presentation accurately displays the outcomes and process measures to drive change.
   10. Conduct a Root Cause Analysis in conjunction with the department directors through record review, and staff interviews on each attributed harm.
2. May assist hospital leaders to maintain a state of Regulatory Readiness. Using tracer methodology supports the department leaders in maintaining an ongoing state of regulatory readiness. Conducts clinical department tracers alongside department leaders providing expertise in the Joint Commission standards and CMS Conditions of Participation.
3. May assist hospital leaders in National Quality Program effectiveness. To help develop units/departments toward mastery level in Foundational Five tools as well as key strategies Leader Rounding, Bed Side Shift Report, and Teach Back, conducts observational auditing.
4. Coordinates and facilitates performance improvement projects identified as identified by the hospital leadership and directed by the department director.

General:

1. Protect confidentiality of all activities and data.
2. Keep department Director informed of all activities, concerns, and improvement opportunities as necessary.
3. Maintains availability and visibility to all departments and medical staff regarding harms reduction.

The above statements reflect the general duties considered necessary to describe the principal functions of the job as identified and shall not be considered as a detailed description of all the work requirements that may be inherent in the position.

ORGANIZATIONAL RELATIONSHIPS

A direct reporting relationship is established to the Department Director. Interacts with medical center personnel, patients, and providers one-on-one and in committee daily. This is fulltime hourly position requiring Monday thru Friday coverage with occasional weekends possible.

EDUCATION AND EXPERIENCE

Bachelor of Nursing degree required. Master of Nursing strongly encouraged. RN license in the state of Montana or compact state license required.  3 years’ bedside acute care experience required.  Certification in Quality (CPHQ), Patient Safety (CPPS) or Performance Improvement (Six Sigma or LEAN) required within 6 months.

 WORKING CONDITIONS

Primarily sedentary, general office environment with daily, frequent use of the telephone and computer requiring near visual acuity.  Walking about the Medical Center to attend rounds and meetings. Lifting of 8-10 pounds if moving or lifting files.  Stooping and bending required for retrieval of files.

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is a logical assignment to the responsibilities, assigned with or without notice.