Overview
Under the supervision of the Quality Director, directs the department activities and resources to achieve departmental and organizational objectives. This position has responsibility for the implementation and review of the facilities infection prevention program and its entirety. The role ensures compliance with departmental and administrative policies and procedures; ensures compliance with The Joint Commission, Local, Stat and Federal Regulatory Agencies; develops and monitors quality improvement programs, participates in interdepartmental quality management; attends hospital and community meetings as appropriate; serves on various committees; investigates incident reports, patient complaints, and patient care issues; and another task as requested by the Director.
Coordinates the development, implementation and revision of the QI program, which meets the needs of patients, staff, and external agencies.
Provides QI leadership and consultative services for hospital and medical staff in effectively achieving regulatory accreditation and organizational compliance for QI activities.
Organizes, compiles, and reports QI data for both the hospital and medical staff departments to identify trends, establish priorities, and recommend improvement activities.
Performs comprehensive, concurrent and retrospective, reviews in a timely manner, utilizing criteria developed and approved by the medical staff and the hospital.
Reports findings to other departments and committees, such as Environment of Care, infection control, and Administration as appropriate.
Serves as a working member of the hospital’s quality council; attends committee meetings and other pertinent meetings to ensure the organization’s overall QI plan implementation and compliance.
Keeps abreast of current TJC standards and other accreditation standards, as well as the latest quality techniques in health care.
Data abstraction for Core Measures and electronic filing of required reports.
Prepares various internal reports concerning Core Measures, Harms data, Leapfrog, etc.
Coordinates data reporting and analysis regarding Core Measures and facilitates quality improvement activities concerning these measures.
Remains current with Joint Commission standards, State Hospital Licensure Regulations and CMS requirements.
Receives complaints/grievances and facilitates review and resolution.
Participates in investigations of legal claims.
Is involved in all root cause analysis investigations as deemed necessary by the Director.
To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.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 position. This position description does not restrict the right of management to assign or reassign duties and responsibilities with and without notice.
Minimum EducationAssociate degree, requiredBachelor’s or Master’s degree, preferredSpecialized training or experience in Statistics, Performance Improvement, Quality Assessment and Assurance, and Regulatory Management strongly preferred.
Minimum Work ExperiencePreferred 3 years RN experienceSpecialized training or experience in Statistics, Performance Improvement, Quality Assessment and Assurance, and Regulatory Management strongly preferred.
Required SkillsRequires critical thinking skills, decision judgment and the ability to work with minimal supervision. Must be able to work in a stressful environment and take appropriate action.Demonstrated initiative, ability to work with others, and good professional judgment.Ability to work independently and organize time effectivelyExcellent written and verbal communication skills.Must be able to function within an interdisciplinary framework and with customer groups that may include all levels of staff, physicians, patients, families and other contacts.
Basic Life Support (BCLS) or higher Advanced Cardiac Life Support (ACLS) within 30 days of hireMust complete CDC Ifnection Control Training within 30 days of hireMust obtain CIC within 4 years of hire
Required Licenses[Arizona, United States] Registered Nurse
Valid Arizona or Compact States nursing license on hire
**Job:** **Quality*
**Organization:** **Valley View Medical Center*
**Title:** *Quality Coord/Infection Prev. – FT Days*
**Location:** *Arizona-Ft. Mohave*
**Requisition ID:** *7451-3216*
