Quality Risk Management Coordinator - Physicians Medical Center

Responsibilities

• Lead, facilitate, and advise the Center Quality Council and internal performance improvement teams.
• Set the agenda and maintain meeting minutes.
• Ensure reporting of all mandatory and center specific monthly and quarterly reports for trends/areas for improvement to the Quality Council and Medical Executive Committee/Governing Body a minimum of quarterly:
• Medical Record Audit reports;
• Monthly or quarterly data collection from ongoing systematic chart review to assess quality of documentation.
• Infection Control reports;
• Hospital Transfer/Complication reports;
• Patient Safety;
• measurement of key measures of patient safety and hazard analysis/process redesign (adverse events, root cause analysis).
• Life safety (environment of care);
• Provide for a detailed assessment and evaluation of the Environment of Care (EOC) and the associated conditions, staff education and readiness and the various processes.
• Framework for the EOC includes the management processes and systems that affect safety, security, hazardous materials, emergency preparedness, life safety, medical equipment, and utilities management.
• Risk Management (incident reporting)
• Adverse Drug Reaction reports;
• Cancellation logs;
• Service Satisfaction reports (patients, staff and physicians)
• Center specific quality indicator reports as appropriate
• PI reports;
• Collection, analysis and summary of performance improvement data.
• Provides strategic oversight of proactive and reactive patient safety activities:
• Root cause analysis.
• Clinical practice guidelines
• Sentinel Event Alerts
• Identification and data collection of center specific quality indicators based on high risk, problem prone procedures as appropriate.
• Review and revision of the PI Plan on an annual basis and preparation of the annual report of the PI program to the Medical Executive Committee/Governing Body.
• Document all Performance Improvement activities and maintenance of records for a minimum of three years.
• Provides strategic oversight of proactive and reactive patient safety activities (continued):
• Coordination of the center policies/procedures and processes to be in compliance with the current standards of applicable regulatory and accrediting agencies, and mandatory SCA Corporate policies.
• Working with the Administrator/designee to ensure currency of all physician files, medical staff appointments and/or privileges and compliance with credentialing policies and procedures.
• Coordinating as appropriate the peer review process and aggregate individual peer review data for presentation and review by the Medical Executive Committee and Governing Body at reappointment.
• Working with the Administrator/designee to ensure currency and completeness of all human resource and education files for center employees and contract personnel.
• Maintain Center Survey readiness:
• Assess center compliance with accreditation standards and regulations in collaboration with leadership and staff.
• Identify areas of vulnerability and direct the development of strategies to enhance compliance.
• Communicate Effectively Throughout All Levels of the Organization:
• Proactively educate and train the leadership and staff regarding regulatory issues, new statutes/guidelines, and safety/quality/performance improvement activities and their respective responsibilities in carrying out the performance improvement program.
• Maintain effective communication on current center activities related to Safety/Quality/PI and Accreditation and seek consultation as needed for support from the Regional Quality Coordinator or assigned Group Director.

Qualifications

• Licenses or Certifications: Licensed Registered Nurse
• Education, vocational training, and experience: Registered Nurse with training and experience in quality/performance improvement and accreditation and regulatory standards.
• Minimum of an Associate’s degree in nursing, Bachelor’s degree preferred
• Work in concert with the Regional Quality Coordinator to implement the SCA strategic clinical-quality plan.
• Possess excellent written and oral communication skills.
• Knowledge of standards, survey methodology and related tools and resources for regulatory and accreditation requirements
• Regularly accesses internal and external resources to maintain professional knowledge base.