|Job Summary: Responsible for planning and implementing the performance improvement program to meet the needs of the hospital. Provides education to medical staff, hospital staff and Governing Body. Facilitates performance improvement activities and CQI activities throughout the hospital. Acts as resource person to administrative team, department managers and medical staff. Assists department managers with preparation for medical staff committees. Assists with preparation for all regulatory body surveys, i.e., State Licensing Review, CMS Validation surveys.
· Gathers, reviews, and evaluates clinical data including patients’ medical records
· Applies quality assurance criteria and nursing documentation standards
· Analyzes data for patterns and trends in care delivery
· Works with leadership and staff to create policies and procedures that ensure good quality care and minimize harm to the patient
· Keeps up to date with applicable federal and state laws and regulations
· Prepares quality documentation and reports by collecting, analyzing and summarizing information and trends including failed processes, corrective actions, and re-assessment.
· Reports data to appropriate Medical and Governing committees.
· Plans and implements the performance improvement program to meet the needs of the hospital.
· Oversees preparation for review by regulatory agencies, educates and assists department managers to maintain appropriate policies and procedures to fulfill requirements and regulations.
· Consults with other departments as appropriate to collaborate in patient care and performance improvement activities.
· Participates in risk management and safety activities.
· Documentation meets current standards and policies.
· Provides support and assistance to medical staff officers, committee chairpersons and Governing Body, as required.
· Utilizes information obtained via performance improvement activities to seek and act on opportunities to improve patient care processes.
· Supports and maintains a culture of safety and quality.
· Perform other job related duties as assigned.
Essential Knowledge, Skills and Abilities:
· Consistently demonstrates a professional, self-directed, mature, disciplined and tactful approach to department responsibilities.
· Demonstrates effective organizational skills through ongoing interaction with clinical chairpersons, nurse managers, ancillary department managers, administrative team and Governing Body to facilitate the hospital wide PI program.
· Practices good guest relations with patients, visitors, physicians and staff, assists as needed.
· Communicates appropriately and clearly to Physicians, DON, staff and administrative team.
· Accurately demonstrates use of database systems to document occurrences, medical staff review functions, committee review and actions. Compiles reports for committees and administrative team.
· Skills in data management as well as the ability to collect, analyze, and present data to groups and individuals.
· Ability to work collaboratively with Physicians, hospital staff, and external organizations.
· General understanding and ability to research Centers of Medicare and Medicaid Services regulations.
· Ability to read, write and follow English verbal and written instructions.
· Knowledge of concurrent and retrospective chart review.
· Knowledge of and experience in Electronic health records.
· Demonstrated ability to develop, organize, facilitate, and lead special projects.
· Demonstrated oral and written communication skills.
· Intermediate computer skills.
· Current RN license from the State of Oklahoma Board of Nursing.
· Three(3) years demonstrated clinical expertise to effectively facilitate evaluation of quality care preferred
· Experience in In Patient and Out Patient documentation requirements, including state regulations and guidance regarding nursing documentation
Note: This is a full time position with flexibility in hours required in order to meet deadline submissions or manage a variety of facility issues requiring Quality presence.
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