Nursing Quality Improvement Coordinator

SBH HEALTH SYSTEM

Department of Nursing

DEPARTMENT: NURSING ADMINISTRATION

POSITION TITLE: NURSING QUALITY COORDINATOR

REPORTS TO: VICE PRESIDENT OF NURSING EDUCATION, QUALITY, AND PROFESSIONAL DEVELOPMENT

SCOPE OF WORK:

The Nurse Quality Coordinator is responsible for coordinating, implementing, monitoring, and evaluating nursing quality improvement and patient safety initiatives throughout the organization. Reporting directly to the Vice President of Nursing Education, Quality and Professional Development, the Nurse Quality Coordinator collaborates with nursing leadership, physicians, interdisciplinary teams, and frontline staff to improve patient outcomes through evidence-based practice, performance improvement methodologies, regulatory compliance, data analysis, and continuous survey readiness.

The Nurse Quality Coordinator supports department-wide initiatives including Joint Commission readiness, nurse-sensitive indicators, blood culture contamination reduction, Bar Code Medication Administration (BCMA) compliance, falls prevention, sepsis recognition and management, documentation excellence, hospital-acquired condition reduction, patient safety event review, and other nursing quality improvement initiatives.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

1. Supports nursing quality improvement initiatives using evidence-based methodologies and performance improvement tools.

2. Assists with the departmental-wide Joint Commission, CMS, Department of Health, and regulatory survey readiness

3. Conducts clinical documentation audits, tracer activities, observational rounds, and regulatory compliance reviews.

4. Monitors nurse-sensitive indicators and collaborates with nursing leadership to improve performance outcomes.

5. Coordinates quality improvement initiatives related to falls prevention, pressure injury prevention, CAUTI, CLABSI, sepsis, and other patient safety priorities.

6. Supports blood culture contamination reduction initiatives through audits, education, data collection, and staff feedback.

7. Monitors Bar Code Medication Administration (BCMA) compliance and collaborates with clinical leaders to improve medication safety practices.

8. Collects, validates, analyzes, and trends nursing quality data and prepares reports for leadership and committees.

9. Develops dashboards, scorecards, and performance reports utilizing internal and external benchmarking data.

10. Participates in Root Cause Analyses (RCA), Failure Mode and Effects Analysis (FMEA), patient safety investigations, and action plan development.

11. Conducts concurrent and retrospective chart reviews to assess compliance with evidence-based standards of care.

12. Provides education to nursing staff regarding regulatory standards, documentation excellence, quality improvement, and patient safety initiatives.

13. Assists departments with implementation and sustainment of corrective action plans following audits and survey findings.

14. Collaborates with Infection Prevention, Risk Management, Pharmacy, Laboratory, Case Management, Information Technology, Education, and Nursing Leadership to improve quality outcomes.

15. Participates in departmental committees supporting quality improvement, patient safety, nursing excellence, and accreditation readiness.

16. Assists with development, revision, and implementation of nursing policies, procedures, clinical guidelines, and evidence-based practice recommendations.

17. Maintains current knowledge of Joint Commission standards, CMS Conditions of Participation, Department of Health regulations, National Patient Safety Goals, and evidence-based clinical practice.

18. Supports nursing research, evidence-based practice initiatives, and dissemination of quality improvement findings.

19. Demonstrates accountability for maintaining confidentiality in accordance with HIPAA and organizational policies.

20. Maintains accurate documentation and records related to quality improvement activities.

21. Demonstrates effective communication, collaboration, and professionalism with all members of the healthcare team.

22. Assists with orientation, mentoring, and education of new nursing staff regarding quality initiatives and regulatory requirements.

23. Demonstrates flexibility in supporting organizational priorities and departmental initiatives.

24. Complies with attendance policies and reports promptly for assigned work schedule.

25. Follows OSHA standards, Infection Prevention policies, and all hospital safety procedures.

26. Demonstrates knowledge of hospital fire safety, emergency preparedness, and disaster response procedures.

27. Adheres to hospital dress code and identification badge requirements.

28. Attends mandatory education programs, department meetings, quality committees, and continuing education activities.

29. Promotes a safe, collaborative, respectful, and professional healthcare environment consistent with HR Policy 113C.

30. Adheres to all hospital policies, procedures, rules, and regulations, including attendance, ETIME, electronic device usage, confidentiality, and standards of conduct.

31. Demonstrates exceptional customer service by treating patients, families, visitors, physicians, and coworkers with professionalism, courtesy, respect, and compassion while promoting the mission and values of St. Barnabas Hospital.

32. Performs other duties and special projects as assigned by the Administrative Director of Nursing Quality and Patient Safety.

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 work requirements that may be inherent in the job.

QUALIFICATIONS:

A. EDUCATION REQUIRED

• Bachelor of Science in Nursing (BSN) required.
• Master's Degree in Nursing, Healthcare Administration, Public Health, Quality, or related healthcare field preferred.

B. EXPERIENCE REQUIRED

• Minimum three (3) years recent acute care nursing experience.
• Minimum two (2) years experience in nursing quality, patient safety, accreditation, performance improvement, leadership, or related healthcare quality role preferred.
• Experience with Joint Commission, CMS, or Department of Health surveys preferred.

C. LICENSURE/CERTIFICATION

• Current Registered Nurse License (New York State)
• BLS Certification

D. PREFERRED CERTIFICATIONS

• Certified Professional in Healthcare Quality (CPHQ)
• Clinical Nurse Leader (CNL)
• Specialty Nursing Certification

E. SKILLS REQUIRED

• Excellent written and verbal communication skills.
• Strong organizational and project management abilities.
• Knowledge of evidence-based practice and quality improvement methodologies.
• Ability to analyze and interpret clinical quality data.
• Experience utilizing Microsoft Office applications and electronic health records.
• Strong interpersonal, leadership, coaching, and presentation skills.
• Ability to work independently while managing multiple priorities.
• Commitment to patient safety and continuous quality improvement.

WORKING CONDITIONS

Hours may vary based upon departmental and organizational needs.

JOB HAZARDS

• Exposure to communicable diseases.
• Potential exposure to blood and body fluids.
• Frequent computer use.
• Prolonged sitting, standing, walking, and participation in clinical observations.
• Occasional lifting of educational materials and equipment.

PATIENT POPULATION

☒ Infant ☒ Children ☒ Adolescents ☒ Adults ☒ Geriatrics

Pay: $130,000.00 - $135,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Vision insurance

Work Location: In person

Benefits:

Salary : $130,000 - $135,000