• Facilitates the documentation of identified indicators and care delivery consistent with evidence based practices and regulatory requirements.
• Develops and reports discrepancies and outcomes.
• Coordinates quality improvement initiatives utilizing proven quality improvement principles, bringing suggestions for improvement in processes to ensure compliance with quality indicators, and management and feedback of team performance data.
• Intervenes concurrently as able to ensure compliance with care provision in accordance with evidence based practices and quality indicator measures.
• Models and coaches the principles of high reliability, safety culture, and continuous learning.
• Maintains information and current knowledge of quality indicator measures, resource management, performance improvement, patient education, and discharge planning processes, including philosophy and principles.
• Applies the appropriate QI tools and methods for successful quality and process improvement projects.
• Develops and maintains professional working relationships with physicians, nursing staff, and other health care providers.
• Abstracts quality measure criteria in the electronic health record.
• Reviews care encounters to identify complications and quality improvement opportunities.
• Applies change management principles.
• Applies patient safety, just culture, and high reliability principles.
• Proficient in the use of QI Macros.
• Creates learning opportunities and materials to advance the organization.
• Demonstrates the ability to facilitate teams and teamwork.
• Keeps abreast of all pertinent federal, state and facility regulations, laws and policies as they presently exist and as they change or are modified.
• Understands and adheres to compliance standards as they appear in the Corporate Compliance Policy, Code of Conduct, and Conflicts of Interest Policy.
• Demonstrates age-specific skills as required by position.
• Offers suggestions on ways to improve operations of department and reduce costs.
• Attends all mandatory education programs.
• Improves self-knowledge through voluntarily attending continuing education/certification classes.
• Maintains required competency levels as identified in written exams, skills checklists, skills labs, annual safety and health requirements as well as service excellence education hours requirements.
• Willing to cross-train in order to better assist co-workers and to provide maximum efficiency in department.
• Volunteers/participates on hospital committees, functions, and department projects.
• Manages resources effectively.
• Reports equipment in need of repair in order to extend life of equipment.
• Makes good use of time so as to not create needless overtime.

Job Summary