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Department: Quality Services and Risk Management
Hours: Fulltime (1.0 FTE, 80 hours per biweekly pay period) – Day Shift
Description:
Position Overview: The Clinical Quality will coordinate the clinical quality program. Responsible for data collection, monitoring, coordinating, and evaluating the quality improvement and risk activities. Fosters awareness and mentorship for colleagues supporting excellence in the environment of care. Promotes high quality care and cost-effective services.
Duties and Responsibilities
- Knowledge and compliance of plans policies and procedures for disaster, fire, safety, infection control and HIPAA.
- Investigates and resolves incidents, injuries and complaints or suggestions from patients, visitors, Medical Center staff. Correct deficiencies, if any, and prepare documentation or explanation(s) as indicated. Refer issues to the Chief Nursing Officer (CNO) as necessary.
- Coordinates organizational quality initiatives and is responsible for the entry, measurement, analysis, and dissemination of data / results.
- Works proactively promoting compliance with regulatory standards.
- Sets clear expectations for colleagues regarding quality improvement and goal setting; inspires others to plan, prioritize quality metrics, and promotes action plans based on data to ensure implementation of processes and improve performance.
- Collaborates with department directors and managers to develop departmental goals and objectives aligned with the organizations strategic plan or goals and is a good steward aligned and fiscally responsive to the organization’s strategic plan.
- Works cooperatively with the Iowa Healthcare Collaborative (IHC), Iowa Hospital Association (IHA) for quality improvement. Serves as a liaison for Quality Improvement Organization (QIO) activities and other entities as appropriate. Be a member of Iowa Association for Healthcare Quality (IAHQ).
- Submits the Quality Committee meeting agenda, conducts the meeting, and submits written minutes from Quality Improvement meetings to the Chief Executive Officer (CEO), CNO, and Board of Trustees.
- Prepares an annual evaluation and summary of medical center-wide Quality Improvement activities for Board of Trustees and for the network hospital.
- Responsible for Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) program and the contracted vendor as the medical center liaison. Ensures feedback is disseminated to appropriate parties. Results shared with department directors, administration, medical staff, and the Board of Trustees. Ensures information is shared with medical center employees.
- Meets productivity expectations of the organization. Is supportive of the organization and leadership.
- Responsible for maintaining certification/ licensure requirements as directed by position.
- Provides leadership by working cooperatively with all colleagues while maintaining standards for professional nursing practice in the clinical setting.
- Reviews all incidents/occurrences. Provides CNO an Occurrence Analysis and Risk Report monthly and as needed. Reports serious and/or unusual patient, visitor, and employee incidents/occurrences to CNO immediately.
- Organizes and leads root cause analyses done on unexpected outcomes or concerns.
- Reports any patient or employee safety or quality concerns timely to the CNO.
- Notifies appropriate administrative and/or department management staff in the event of a crisis or emergency.
- Performs all other duties and responsibilities as assigned or requested by the CNO.
Minimum Education and/or Experience Required:
- Bachelor of Science in Nursing (BSN) required, Master of Science in Nursing (MSN) preferred.
- Minimum of five years of hospital and clinical experience.
- Two years of leadership experience preferred.
- Experience in quality preferred.
Additional Qualifications:
- Excellent oral and written communication skills required.
- Must be able to read, speak, and write fluent English.
- Excellent analytical skills and attention to detail
- Ability to prioritize assignments and manage time efficiently.
- Ability to plan, organize, and conduct meetings.
- Self-starter and able to work independently and in group settings.
- Strong computer skills required including Microsoft Word and Excel, PowerPoint preferred.
- Possess professional and leadership qualities.
- Critical thinking, ability to adapt and respond positively to change and the health care environment.
- Must be flexible.
- Ability to define problems, collect information, establish facts, and draw valid conclusions.
- Ability to operate technologies and equipment associated with this position.
- Ability to work outside of regularly scheduled hours if needed.
Licensure/Certification Required:
- Current licensure as a Registered Nurse in the State of Iowa.
- Certified Professional in Healthcare Quality (CPHQ) preferred.
Physical/Cognitive Requirements:
- Sit: Constant
- Stand: Frequent
- Walk: Frequent
- Lift:
- 10 pounds: Frequent
- 25 pounds: Occasionally
- 50 pounds*: Occasionally
- 75 pounds*: Occasionally
- Greater than 100 pounds*: Occasionally
- Carry:
- 10 pounds: Frequent
- 25 pounds: Occasionally
- 50 pounds*: Occasionally
- 75 pounds*: Occasionally
- Greater than 100 pounds*: Occasionally
- Push/Pull:
- 10 pounds: Frequent
- 25 pounds: Occasionally
- 50 pounds*: Occasionally
- 75 pounds*: Occasionally
- Greater than 100 pounds*: Occasionally
- Squat/Kneel/Crouch: Frequent
- Climb: Occasionally
- Balance: Occasionally
- Twist: Occasionally
- Bend/Stoop: Frequent
- Crawl: Occasionally
- Grasp/Grip: Frequent
- Talk: Constant
- Hear: Constant
- See: Constant
- Anything greater than 50 pounds – assist of two or more, or mechanical lift are required.
Environmental Factors:
- May be exposed to communicable diseases due to working in a health care environment.
- Works in a well-illuminated climate-controlled environment.
- Work environment is comfortable, with minimal exposure to physical hazards.
- Moderate noise level when machines/equipment in use but typically quiet environment.
Organizational Relationships:
Reports to: Chief Nursing Officer (CNO)
Employees supervised: None.