Quality Coordinator

JOB SUMMARYThe Quality Coordinator facilitates and monitors quality improvement through data collection, analysis, actions and resolutions throughout the facility as well as assesses, develops, implements, and evaluates the internal and external education offerings of Morrison Community Hospital according to evidence based practices and in compliance with regulatory guidelines. Act as a quality improvement resource person for all divisions/departments of MCH, assisting each division/department manager in the development and implementation of their respective quality plans.b.

JOB SUMMARYThe Quality Coordinator facilitates and monitors quality improvement through data collection, analysis, actions and resolutions throughout the facility as well as assesses, develops, implements, and evaluates the internal and external education offerings of Morrison Community Hospital according to evidence based practices and in compliance with regulatory guidelines. This position is highly confidential and will require a high level of understanding of organizational priorities, structures, goals, and will require access to sensitive operational data and information systems. This position is responsible for designing and carrying out designated projects including the customer service initiative; facilitating implementation of process changes; and communicating results and findings throughout the organization as appropriate. The Quality Coordinator works under the general supervision of the Chief Nursing Officer and closely with the Nursing Staff, Administration, Providers, patients, front line staff and others as appropriate. ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬ESSENTIAL FUNCTIONS 1. Responsible for the Quality Improvement initiatives at Morrison Community Hospital (MCH) as evidenced by; a. Assist the medical staff department and committees in the development, and implementation of quality control and improvement activities.b. Establish mechanisms for data collection, summarization of findings, and preparation of summary reports of quality control/improvement activities to the medical staff departments and committees.c. Monitor findings from high risk case reviews as performed by the medical staff departments and committees and integrate findings into the credentialing process.d. Attend medical staff department and committee meetings, acting as staff resource person for these meetings.e. Chair of the Quality Improvement Committee, meeting on a monthly basis.f. Monitor all quality activities reported by each medical staff department and each MCH division/department for trending analysis and problem identification, corrective actions implemented and problem resolution.g. Assist, and participate in, the survey review process, as it relates to the evaluation of hospital and medical staff quality activities.h. Provide Quality Improvement/Process Excellence training to employees on a regular basis. i. Develop and revise policies for quality improvement, infection control, employee health, case and risk management. j. Identifies opportunities to coordinate data collection and reporting with the complimentary activities of risk management, incident reporting, infection control, customer safety, medical staff credentialing and peer review. 2. Responsible for the monitoring and compliance at Morrison Community Hospital (MCH):a. Patient incident reports for potential compensatory incidents.b. Oversee trending of all incidents for unusual or recurring events which need process review/improvement. 3. Responsible for Morrison Community Hospital's Customer Service Initiative.a. Receive and address patient concerns with necessary follow up (physician, staff, processes, etc.) to ensure the situation is remedied and prevented from reoccurring.b. Provide staff education and training on providing appropriate customer service.c. Ensure the organization's customer service values are being upheld in daily operations. 4. Responsible for the oversight of the Process Improvement Programs for Morrison Community Hospital (MCH). a. Act as a quality improvement resource person for all divisions/departments of MCH, assisting each division/department manager in the development and implementation of their respective quality plans.b. Acting as staff resource person for QI activities and pathway development (Lean, Six Sigma, TQM, and others)c. Assist and maintain the ongoing monitoring and reporting of clinical pathway/algorithm development to ensure proper utilization of resources and improvement in quality of care. d. Correlates data from quality activities to include problem identification, investigation and resolution. Monitors and trends patterns of care.e. Provides an annual review of the Performance Excellence/Risk Management programs and identifies opportunities for program improvement. 5. Responsible for the organization's clinical education.a. Assists Human Resources and Department Leaders in maintaining all necessary records to meet regulatory guidelines.b. Assists the Chief Nursing Officer in attainment of department goals and initiatives. c. Serves as a resource person for staff.d. Promotes technical competence of staff and develops action plans with staff to achieve expected standards.e. Monitors compliance to practice guidelines - standards of care, protocols and evidenced-based practices.f. Encourages staff to participate in the performance improvement process. g. Assists in compliance with regulatory agencies (IDPH, etc.) through educational opportunities. 6. Responsible for maintaining regulatory compliance in all efforts related to Quality/Education and Customer Service. a. Understands and complies with all State and Federal regulations governing quality, and risk management. b. Knowledgeable of regulatory guidelines for the Illinois Department of Public Health. c. Oversee gathering of data and submission of reports for quality indicator studies and any external studies being done.d. Evaluates and assumes the role of team lead for survey processes such as Critical Access Hospital guidelines, etc. e. Prepares and submits various regulatory reports (Press Gainey, CMS, ICAHN, Leapfrog, etc.). 7. Exhibits behaviors compatible and in support of Morrison Community Hospital's Mission as evidenced by; a. Resolves problems and concerns in a constructive manner. b. Assists and supports others when appropriate. c. Influences and supports others in a positive manner. d. Makes positive contributions to the department and Hospital.e. Exhibits objectivity and openness to others views. f. Collaborate with the administrative staff, the governing body, other departmental personnel, physicians and representatives of allied groups, in planning services for the patients. QUALIFICATIONS - Nursing degree (BSN preferred) with current Illinois licensure or a Bachelor's degree in HealthCare Administration, Management, etc. with applicable experience.- Previous experience in performance improvement/assessment, process excellence, and customer service principles required. - Minimum of two years nursing experience.- Knowledgeable of State, Federal and Critical Access Hospital regulations. - Proficient with Microsoft programs including; Word, Excel, and PowerPoint.- Strong oral and written communication and interpersonal skills.- Must be comfortable operating in a collaborative, shared leadership environment, function as a team member and maintain good working relationships.- Must possess a personal presence that is characterized by a sense of honesty, integrity, and caring.