Quality Clinical Safety Coordinator - Quality Mgmt/Clinical Safety - Full Time/Days - Req#2117934814

Job Objective:

Under the direction of the Manager of Quality and Clinical Safety, this position is responsible for coordinating quality clinical safety activities, as part of the Performance Improvement (PI)/Quality Management (QM) and Clinical Safety (CS)/Risk Management programs (RM). Activities include patient care processes, outcomes, organizational functions, data collection, and regulatory preparation.

Duties and Responsibilities:

• Participates in the design and development of multidisciplinary and interdisciplinary processes to support and address the situation or issue such as Quality Improvement (QI) initiatives or Teams.
• Facilitates multidisciplinary teams and provides direction to enhance effectiveness.
• Contributes to the development and continuous improvement of organizational systems that support the performance improvement and risk management programs.
• Completes focus review or other quality studies and reports for presentation to QM, Medical Staff and/or other Hospital Committee meetings.
• Fosters organization systems that support implementation of the CS Plans and RM Plans.
• Supports clinical safety activities and functions.
• Develops statistical reports and conducts data analysis as part of the QI cycle.
• Acts as a member and representative for organization committees, including Medical Staff Department or Performance subcommittees, as assigned.
• Reviews and analyzes sentinel events/near misses with appropriate medical and/or hospital staff.
• Conducts case summaries, analysis, and preparation of timelines and succinct written reports for QM or RM.
• Coordinates and conducts intense analysis and ensures timely follow-up of activities.
• Assists and supports the peer review process including Ongoing or Focused Professional Practice Evaluation studies.
• Uses the results of evaluation analyses to make or recommend process or structural changes, including policy, procedure, or protocol documentation, as appropriate.
• Implements initiatives to evaluate the need for change.
• Contributes to the development and continuous improvement of organizational systems that support the planning process
• Analyzes and trends reports from the Patient Safety Electronic Event Reporting program. Collaborates with staff to complete follow-up investigation as needed.
• Coordinates follow-up responses to 3rd parties and as back-up to the Director for patient grievances and other communication with Patient Guest Relations.
• Supports the Regulatory Coordinator in the direction of Clinical Safety functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff with emphasis on clinical safety.
• Assists the director in providing staff education on QM, CS, or RM topics.
• Works with Regulatory Coordinator in the direction of QM and RM functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff.
• Manages, aggregates, and reports information derived from the hospital-wide event reporting system and/or other sources.
• Confidentiality
• • Refrains from disclosing confidential information acquired in the course of work except when authorized, unless legally obligated to do so.
  • Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties
  • Refuses any gift, favor or hospitality that would influence or would appear to influence actions

Non-Essential Duties:

• Other duties as assigned by the Director of Quality Management, Clinical Safety and Infection Control

Knowledge, Skills and Abilities:

Knowledge

• Current knowledge of QM and CS principles.

• Knowledge of Regulatory and Accrediting bodies such as CMS, JC, State Department of Health and insurance providers.

• Maintains an appropriate level of professional competence by ongoing development of knowledge and skills.

Skills

• Strong communication skills to include group presentations

• Skill and ability to follow the established Customer Service Expectations and Standards

• Computer skills to include data entry. Working knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, and Word)

• Demonstrated expertise in systems analysis and management skills at a minimum of an assistant director level

Abilities

• Ability to work effectively with hospital and medical staff professionals

• Ability to handle patient care concerns with objectivity and professionalism

• Uses current research findings and other evidence to expand knowledge, enhance role performance, and increase knowledge of professional issues.

AVMC Values: All AVMC employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.

Education and Experience:

Education

• BSN required to be completed within three years or 5 years of experience in lieu of degree.

• MSN or MS equivalent preferred.

• Certification in either Quality or Risk Management desired.

Experience

• Three years’ Clinical experience in Acute Hospital preferred.

• Experience or training in statistical methodologies and data analysis preferred

Required Licensure and/or Certifications:

• Current California Registered Nursing or LVN license

AVMC Conduct/Compliance Expectations:

• Ability to adhere with AVMC Attendance and Punctuality Policy.

• Ability to adhere with AVMC Leaves of Absence Policy.

• Ability to adhere with AVMC Paid Time Off (PTO) Policy.

• Ability to adhere to the department dress code.

• Ability to organize work and establish priorities.

• Ability to expand on own initiative in performance of duties.

• Skill and ability to follow the telephone etiquette/standards.

• Ability to function effectively under pressure and meet time parameters.

• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff.

• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVMC.

• Ability to maintain the confidentiality of patient, hospital and department information.

• Ability to adhere to safety rules and regulations.

• Safely and effectively uses all equipment necessary to carry out duties.

• Ability to interpret and function under hospital and department policies and procedures.

• Conforms with required and appropriate accreditation and regulatory requirements.

• Conforms with and supports hospital quality assurance and improvement guidelines.

• Ability to participate effectively in department and hospital staff education.

• Display a willingness to work as a team player.

• Ability to give and support the highest level of patient/customer satisfaction at all times.

• Supports and adheres to the values and mission statement established by the AVMC Board of Directors.

• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.

• Ability to follow the Code of Conduct.

Physical Requirements and Working Conditions:

• Work is often performed under stressful, emotional and physical conditions for the office environment
• Work is performed both in an office and nursing unit environment
• Must be able to make walking rounds and conduct record reviews and/or speak with patient/family as needed throughout the hospital

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

Education and Experience:

Education

• BSN required to be completed within three years or 5 years of experience in lieu of degree.

• MSN or MS equivalent preferred.

• Certification in either Quality or Risk Management desired.

Experience

• Three years’ Clinical experience in Acute Hospital preferred.

• Experience or training in statistical methodologies and data analysis preferred

Required Licensure and/or Certifications:

• Current California Registered Nursing or LVN license