Job Summary

Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff, and Governing Body. Facilitates performance improvement activities, and CQI activities throughout the hospital. Acts as resource person to administrative team, department manager's, and medical staff. Performs clinical risk management functions. Assists department managers with preparation for medical staff committees. Oversight responsibility for all regulatory body surveys, such as, JCAHO, State Licensing Review, HCFA (CMS) Validation surveys. Maintains oversight responsibility for all performance improvement activities conducted throughout the hospital. Manages employee health services and the hospital's Worker's Compensation program. Implements an effective hospital-wide infection control program in keeping with Centers for Disease Control (CDC), JCAHO, and other regulatory agencies. Plans, coordinates and teaches continuing education and in- service education for the hospital, including General Orientation. Develops monthly education calenda. Ensures Scion HealthCare's compliance training is completed annually. Collaborates with managers and peers to evaluate staff competency.

Essential Functions

• Responsible for planning and implementing the performance improvement program to meet the needs of the hospital.
• Facilitates performance improvement and CQI activities throughout the hospital through effective organizational skills and ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team, and Governing Body to facilitate the hospital-wide Performance Improvement program.
• Maintains awareness of changes in the regulations and requirements by accrediting bodies and current methodology and practices.
• Manages and operates equipment safely and correctly.
• Communicates appropriately and clearly to physicians, staff, and administrative team.
• Uses database systems to document occurrences, medical staff review functions, committee review and actions. Compiles reports for committees and administrative team.
• Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations.
• Maintains a good working relationship both within the department and with other departments. Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.
• Participates in risk management and safety activities.
• Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required.
• Manages employee health initiatives such as maintaining employee health files, employee TB screenings/chest x-rays, vaccines and the Hebatitis B program.
• Coordinates new employee health screenings.
• Identifies employee illnesses, exposures and injuries in order to assess risk potential for prevention of transmission or recurrences.
• Institutes employee work restrictions if the potential for transmission of infection exists.
• Enters incident/claim information into the Event Reporting System (ERS).
• Acts as a liaison for OSHA or Department of Industry, Labor and Human Relations (DILHR) inspections.
• Maintains the OSHA log.
• Develops, implements and continually monitors the infection control policies and procedures for all departments.
• Implements a surveillance system for detecting and monitoring hospital acquired and community infections. Ensures compliance to regulatory requirements.
• Investigates outbreaks or clusters of infections. Monitors, analyzes, and interprets bacteriology reports and infection statistics, recommends appropriate control measures to prevent dissemination of resistant microorganisms and pathogens.
• Consults with physicians, managers, and staff for the management of infectious and/or immunosuppressed patients.
• Participates in Infection Control Committees.
• Collaborates with local and state health departments in the prevention, control, and appropriate reporting of communicable diseases.
• Participates in ongoing infection control educational programs for employees, including TB, HIV/Hep/Universal Precautions. May educate patients as necessary.
• Acts as a resource person for staff concerning infection control.
• Undertakes regular infection control audits and appropriate follow up action where required.
• Determines and develops short-term and long-term educational goals based on needs identified through Quality Council, Annual Assessments, specific training needs assessments.
• Oversees development, planning and coordination of general hospital orientation. Coordinates with various departments to include their specialty area.
• Maintains specific orientation modules for new IP, RN and LPN/LVN.
• Managers planning and coordinator of continuing and in-service education.
• Ensures that the hospital's employees receive compliance training and education necessary to perform their job responsibilities.

Knowledge/Skills/Abilities/Expectations

• Excellent oral and written communication and interpersonal skills.
• Basic computer skills with working knowledge of Microsoft Office, word-processing and spreadsheet software.
• Knowledge of current state, federal and local laws and regulations governing employee healthcare needs.
• Knowledge of accreditation standards and compliance requirements.
• Ability to maintain confidentiality of all patients and/or employee information to assure patient and/or employee rights are protected.
• Ability to demonstrate critical thinking, appropriate prioritization and time management skills.
• Ability to work under stress and to respond quickly in emergency situations.
• Ability to spend a limited amount of time on travel required.
• Must have good and regular attendance.
• Must read, write and speak fluent English.
• Performs other related duties as assigned.

Education

• Bachelor's Degree in nursing required.
• Master's degree in nursing or a healthcare related field preferred.
• Additional state requirements as applicable.

Licenses/Certification

• Licensed as a Registered Nurse in state.
• BLS certification required.
• Certified Professional Healthcare Quality (CPHQ) certification preferred.

Experience

• Minimum three years' experience in Quality and/or Risk Management in a hospital setting.
• Prior clinical preceptor or management experience required.