Quality Program Coordinator RN - Stroke/Sepsis

JOB SUMMARY :

Assists the Director in maintaining and revising the Quality and Performance Improvement program, projects, and initiatives across the Hospital.

Coordinates the activities of departments, committees, and medical staff to develop and document ongoing evaluation activities.

Performs studies and problem-focused reviews; interprets data; develops and implements action plans; and monitors and evaluates performance.

Promotes the Quality and Performance Improvement program to medical, nursing and support services. Responsible for coordinating stroke and sepsis programs and other duties, as assigned.

EXPERIENCE / QUALIFICATIONS :

Basic Qualifications :

• Minimum five (5) years of experience as a licensed hospital nurse required.
• Minimum three (3) years of experience in quality-related activities such as Medical Staff Peer Review, Quality Management, Performance Improvement, Disease-Specific Care Program Management, or Patient Safety / Risk Management.
• Strong planning, interpersonal and conflict resolution skills.
• Effective communication skills including speaking, writing, listening, and facilitating.Able to receive and effectively give information in person, by telephone / video, and in writing.
• Detail-oriented and organized.
• Ability to independently prioritize, analyze, and apply critical thinking to achieve resolutions, as well as work collaboratively with key stakeholders.
• Knowledge of licensing regulations, CMS clinical quality measures, DNV Healthcare accreditation standards, and primary stroke center requirements.
• Proficient with PC applications including email, presentation, spreadsheet, and word processing. Microsoft experience preferred.

Preferred Qualifications :

• Experience in a quality improvement related role, including leading / facilitating teams in performance improvement.
• Knowledge of ISO 9001

EDUCATION :

• Graduate of an accredited school of nursing or related clinical health program required.
• Bachelor's degree in nursing required.
• Master’s Degree or equivalent preferred

LICENSURES / CERTIFICATION :

• Current licensure with the California Board of Registered Nursing.
• Must successfully complete and maintain LA City Fire Card certification at the time of hire or within the first 30 days of employment.
• Current Certified Professional of Healthcare Quality (CPHQ) preferred.

DUTIES AND RESPONSIBILITIES ( These are the essential job functions for this position. The essential functions of this job include, but may not be limited to those listed in this job description.

Employees hired for this position must be able to perform the essential function of this job without imposing significant risk of substantial harm to the health or safety of themselves or others) :

• Consults with department leaders, medical staff, and key stakeholders to assist them in developing ongoing evaluation programs to identify, resolve, and report opportunities to improve patient care.
• May represent the Department on medical staff committees.
• Designs, conducts, and evaluates studies and problem-focused reviews requested by Administration, medical staff, or department leaders which frequently involve sensitive, confidential, or medical legal issues.
• Performs and oversees ongoing quality improvement activities across the organization to assure timeliness, accuracy, and compliance with licensing, certification, program and / or regulatory requirements.
• Uses and educates end users on data display and performance improvement tools, including statistical process control methods and process maps, Plan-Do-Study-Act model.
• Leads and facilitates project / initiative teams to develop and improve processes for achieving outcomes.
• Assists in the preparation of reports that are sent to medical staff committees, Administration, and the Board of Directors.
• Quality : Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, recognizes and acts on quality problems.

Data results are validated prior to presentation and / or submission to external agencies. Reference sources are easily retrieved and available.

The information provided is concise yet thorough. Corrections to work product are kept at a minimum and not repetitive in nature.

• Project Management : Establishes project goals, milestones, and procedures, defines roles and responsibilities, acquires project resources, coordinates projects throughout organization, monitors project progress, manages multiple projects.
• Ensures requirements for primary stroke center certification are met as set forth by DNV Healthcare and Los Angeles County Emergency Medical Services by capturing data, auditing chart, and submitting monthly and quarterly reports.

Co-leads Stroke Committee with Stroke Medical Director.Presents reports at meetings from data analysis. Develops and delivers stroke education in collaboration with Staff Education Department.

• Coordinates the Hospital’s sepsis program in alignment with guidelines published by the Centers for Disease Control and Prevention.
• Performs other duties as assigned.

The following job accountabilities are not unique to this particular job but are common to all jobs at VPH :

Complies with VPH policies and procedures on customer satisfaction and service excellence.Demonstrates professionalism and cultural sensitivity in coordinating activities and communicating with all customers, peers, and the community at large.

Conducts self in a professional, respectful, and courteous manner during all interactions.Works effectively and collaboratively with others toward common goals.

Communicates accurately, honestly, supportively and in a timely manner with department and interdepartmental team members.

Demonstrates effective business writing and oral communication skills, handwriting is clear and legible.

• Participates in operational aspects of the department and maintains / participates in performance improvement activities within the department.
• Participates in all departmental specific training, Environment of Care (injury / illness prevention, fire / life safety, hazardous materials, emergency preparedness, utilities management, medical equipment management, safety, and security management), infection control (standard precautions, TB Exposure Control Plan, Bloodborne Pathogen Exposure Control Plan).
• Demonstrates knowledge of and follows safety practices.Understands the importance of safety, including patient safety in the workplace.

Maintains a safe environment for self and others.

Actively participates in the Patient Safety Program, including event reporting.Identifies sentinel events / near misses and responds per defined organization processes.

Participates in education activities and process implementation.Demonstrates advocacy for the patient / customer and appropriately acknowledges patients, customers, and visitors.

The above statements reflect the essential functions considered necessary to describe the principal content of the job.

They are not intended to be a complete statement of all work requirements or duties that may be inherent in the job.

WORK ENVIRONMENT :

• Primarily an inside building / office environment, well lighted and ventilated, which may consist of multiple treatment and / or work sites.
• Fast and continuous work pace with variable workload.
• Frequent contact with staff and public under a variety of circumstances.Requires ability to communicate clearly (in English) verbally and in writing for effective communication with other staff members, physicians, vendors, community members, patients and patient families, employees, and applicants of all socio-economic levels from a diverse cultural and ethnic population.
• Subject to many interruptions from multiple calls and inquiries and potentially emotional situations involving accidents, injuries, illness and / or death.
• Handles emergency / crisis situations in accordance with Hospital policy.
• Answers phones or pages; may carry a beeper / pager, and / or use a two-way radio.
• Occasional travel may be required.
• Potential risk of exposure to hazards from chemicals (toxic and non-toxic), flammable materials, gas or electrical or radiant energy or equipment with / without moving parts.

PHYSICAL DEMANDS :

Continuous 66 to 100% of timeFrequent 33 to 65% of timeOccasional 0 to 32% of time

Clerical / Administrative Non-Patient Care

• Frequent / continuous sitting with occasional, intermittent standing / walking.
• Continuous use of bilateral upper extremities in fine motor activities requiring fingering, grasping, and forward reaching between waist and chest level.
• Occasional / intermittent reaching at or above shoulder level.
• Occasional / intermittent bending, squatting, kneeling, pushing / pulling, twisting, and climbing.
• Occasional / intermittent lifting and carrying objects / equipment weighing up to 25 pounds.
• Continuous use of near vision, hearing, and verbal communication skills in handling telephone calls, interacting with customers and co-workers and performing job duties.
22 days ago