Clinical Quality Administrator- Full Time Days

Cape Fear Valley Health

8d•Onsite

About The Position

The Clinical Quality Administrator serves as an expert resource for advancing Quality and Patient Safety (PS). The role supports quality and performance improvement for the organization and its Medical Staff by participating in and coordinating activities involving the acquisition, aggregation, and analysis of relevant data and applying findings to improve clinical and work processes. The administrator helps maintain constant preparedness for Joint Commission, CMS, and other regulatory inspections, and develops, manages, and coordinates quality and evidence-based patient care. The role also provides education and leadership on patient floors to improve quality metrics in disease-specific areas. The administrator works with teams and leaders on process improvement education, prepares and supports quality and patient-safety reporting and meetings, identifies and mitigates safety risks, and coordinates assigned analyses and regulatory survey activities. The position supports consistent standards of interdisciplinary care and systems for transitions from acute inpatient care to outpatient follow-up.

Requirements

Bachelor of Science in Nursing.
Current North Carolina Registered Nurse licensure or compact-state licensure.
At least 2 years of experience working with Quality/Patient Safety and Regulatory, Quality Process, and/or Data Analysis.
Proficiency in reading, writing, and speaking English.
Knowledge of PI methodologies, Joint Commission and CMS standards, and patient safety issues.
Knowledge of quality planning, cost of quality, and the importance of documentation.
Knowledge of basic statistics, distributions, probability, and measurement scales.
Skills in the audit process, including audit types and audit roles and responsibilities.
Skills working with teams, including team-building techniques and team roles and responsibilities.
Ability to collect, aggregate, and review data.
Ability to move throughout the Health System; visual acuity to review data and reports and observe process flows; audiological acuity to monitor group discussions and interactions; verbal ability to express ideas and views effectively to staff; and ability to lift 35 pounds.
No anticipated occupational exposure to bloodborne pathogens or body fluids.
Required RN certification/licensure through the Board of Nursing.

Nice To Haves

Nurse Practitioner (NP) preferred.
Experience with regression and correlation, hypothesis testing, and design of experiments (DOE).

Responsibilities

Educate staff on patient floors to help improve quality of care and CMS/Leapfrog metrics.
Provide ongoing education to Team Leaders, Facilitators, and Members on processes, data analysis, and tools.
Support monthly reports to the Quality Council/Patient Safety Team, Medical Executive Committee, and Board of Trustees on Performance Improvement, Patient Safety, and Regulatory matters.
Coordinate hospital-wide PI/PS/Regulatory meetings as assigned.
Identify and mitigate patient safety risks, and coach staff, leaders, and physicians in safe practices.
Use project management tools as needed to interpret data.
Apply lean tools and processes to reduce waste in cost, inventory, labor, and distance.
Coordinate Root Cause Analyses and Failure Mode and Effect Analyses as assigned.
Maintain knowledge of current Joint Commission and CMS standards.
Assist with the tri-annual Joint Commission survey and CMS and DHSR surveys.
Stay current with CMS and other regulatory standards related to Core Measures.
Assist multidisciplinary teams in developing, implementing, and monitoring systems for transitions of care from acute inpatient care through outpatient follow-up.
Participate in and support the Joint Commission DSC process and performance measure compliance.
Evaluate interdisciplinary care processes to ensure consistency in standards of care and practice.
Perform other duties as assigned.