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Job Objective: Under the direction of the Department Director is responsible for coordinating quality clinical safety activities, as part of the Performance Improvement (PI)/Quality Management (QM) and Clinical Safety (CS)/Risk Management programs (RM). Activities include patient care processes, outcomes, organizational functions, data collection, and regulatory preparation.
Essential Duties and Responsibilities:
- Participates in the design and development of multidisciplinary and interdisciplinary processes to support address the situation or issue such as Quality Improvement (QI) initiatives or Teams.
- Facilitates multidisciplinary teams and provides direction to enhance effectiveness.
- Contributes to the development and continuous improvement of organizational systems that support the performance improvement and risk management programs.
- Completes focus review or other quality studies and reports for presentation to QM, Medical Staff and/or other Hospital Committee meetings.
- Fosters organization systems that support implementation of the CS Plans and RM Plans.
- Supports clinical safety activities and functions.
- Develops statistical reports and conducts data analysis as part of the QI cycle.
- Acts as a member and representative for organization committees, including Medical Staff Department or Performance subcommittees, as assigned.
- Reviews and analyzes sentinel events/near misses with appropriate medical and/or hospital staff.
- Conducts case summaries, analysis, and preparation of timelines and succinct written reports for QM or RM.
- Coordinates and conducts intense analysis and ensures timely follow-up of activities.
- Assists and supports the peer review process including Ongoing or Focused Professional Practice Evaluation studies.
- Uses the results of evaluation analyses to make or recommend process or structural changes, including policy, procedure, or protocol documentation, as appropriate.
- Implements initiatives to evaluate the need for change.
- Contributes to the development and continuous improvement of organizational systems that support the planning process
- Analyzes and trends reports from the Patient Safety Electronic Event Reporting program. Collaborates with staff to complete follow-up investigation as needed.
- Coordinates follow-up responses to 3rd parties and as back-up to the Director for patient grievances and other communication with Patient Guest Relations.
- Supports the Regulatory Coordinator in the direction of Clinical Safety functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff with emphasis on clinical safety.
- Assists the director in providing staff education on QM, CS or RM topics.
- Works with Regulatory Coordinator in the direction of QM and RM functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff.
- Manages, aggregates and reports information derived from the hospital-wide event reporting system and/or other sources.
Maintains an appropriate level of professional competence by ongoing development of knowledge and skills.
Refrains from disclosing confidential information acquired in the course of work except when authorized, unless legally obligated to do so
- Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties
- Refuses any gift, favor or hospitality that would influence or would appear to influence actions
- Other duties as assigned by the Director of Quality Management, Clinical Safety and Infection Control
Knowledge, Skills and Abilities:
- Current knowledge QM and CS principles.
- Knowledge of Regulatory and Accrediting bodies such as CMS, JC, State Department of Health and insurance providers.
- Strong communication skills to include group presentations
- Skill and ability to follow the established Customer Service Expectations and Standards
- Computer skills to include data entry. Working knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, and Word)
- Demonstrated expertise in systems analysis and management skills at a minimum of an assistant director level
- Ability to work effectively with hospital and medical staff professionals
- Ability to handle patient care concerns with objectivity and professionalism
- Uses current research findings and other evidence to expand knowledge, enhance role performance, and increase knowledge of professional issues.
Core Competencies: All AVH employees will effectively demonstrate these behaviors:
Ethics & Values
Integrity & Trust
Education and Experience:
- BSN required or to be completed within three years.
- MSN or MS equivalent preferred.
- Certification in either Quality or Risk Management desired.
- Three years Clinical experience in Acute Hospital.
- Experience or training in statistical methodologies and data analysis preferred
Required Licensure and/or Certifications:
- Current California Registered Nursing license
- Obtains and maintains professional certification if available in the area of expertise, if available/applicable
Physical Requirements and Working Conditions:
- Work is often performed under stressful, emotional and physical conditions for the office environment
- Work is performed both in an office and nursing unit environment
- Must be able to make walking rounds and conduct record reviews and/or speak with patient/family as needed throughout the hospital
A detailed description of the physical requirements of this job is maintained in the Employee Health Department.
Looking for an opportunity to work in healthcare the way you always dreamed you could? At Antelope Valley Hospital, our employees are at the heart of what we do best delivering high quality, patient-centered healthcare.
Antelope Valley Hospital, a 420 bed acute care facility, located just 60 miles north of Los Angeles, the Antelope Valley is one of Southern Californias fastest growing communities. We are a Level II Trauma Center and Joint Commission Primary Stroke Center Accredited. Serving the community for over 50 years, our non-profit hospital has grown to be the preeminent healthcare facility for our districts nearly 1.2 million residents.
An Equal Opportunity Employer.
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