Infection Prevention /Quality Coordinator

Overview

The primary function of the Quality/Patient Safety Program Manager is to support, coordinate, and facilitate the quality

management (QM), patient safety (PS) and regulatory performance improvement (PI) activities for the hospital and

medical staff.

Responsibilities

$7,500 Sign on Bonus Available

Monday-Friday; no weekends or holidays

.5 FTE of this position will be doing Infection Prevention in a supportive role. Checking isolation, looking at charts to make sure we are doing foley cares and central line cares.

Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and

Performance Improvement activities for assigned hospital and medical staff departments, committees, divisions, service

lines and functions. Proactively coordinates and facilitates performance improvement teams to support key initiatives,

including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient

experience, efficiency, FMEAS, root cause analyses and medical staff improvement (e.g. case review for peer review,

OPPE, FPPE).

Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and

reporting of process and outcome measures. Facilitates development and implementation of data collection tools and

processes including the ability to: identify data elements needed to complete appropriate measurement, perform data

collection and abstraction per specifications, and validate data prior to submission or preview reports prior to

publication.

Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.

Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these

regulations in order to improve management of outcomes and ensure compliance.

Assists with regulatory readiness and survey preparation activities including mock survey tracers.

Qualifications

Licensed Registered Nurse

Current state license in a clinical field in state of practice.

Must be able to perform case reviews for medical staff peer review and medical and/or surgical Registry Abstraction

One (1) year healthcare‐related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.)