Quality & Safety Coordinator

Jefferson Community Health Center•Fairbury, NE

About The Position

The Quality & Safety Coordinator coordinates, implements, monitors, and evaluates Jefferson Community Health & Life’s organization-wide Quality Assessment and Performance Improvement (QAPI), Infection Prevention and Control, Employee Health, Risk Management, and Patient Safety programs. The role coordinates quality data collection, analysis, and reporting; facilitates performance improvement initiatives; investigates patient safety events; and supports compliance with applicable federal and state regulations. Working collaboratively with executive leadership, medical staff, department managers, Human Resources, and other healthcare professionals, the coordinator supports improved patient outcomes, reduced organizational risks, employee and patient safety, and continuous improvement. The coordinator independently coordinates assigned programs and is responsible for timely reporting, investigations, monitoring, and recommendations, but has no direct supervisory authority. Department managers remain responsible for operational changes in their departments. The COO provides administrative oversight and retains primary responsibility for legal matters, liability claims, and decisions requiring executive approval. The position is 40 hours per week, Monday through Friday, and is non-exempt. The coordinator serves as the organization’s designated Infection Preventionist, subject to applicable qualifications and training requirements, and maintains clinical competencies for immunizations, occupational exposure assessments, and assigned employee health responsibilities within the RN scope of practice.

Requirements

Graduate of an accredited professional nursing program.
At least three years of clinical nursing experience.
Current unrestricted Nebraska RN license or a valid multistate RN license authorizing practice in Nebraska.
Complete required infection prevention training and maintain appropriate competencies.
Maintain clinical competencies necessary to administer immunizations, assess occupational exposures, and perform assigned employee health responsibilities within the RN scope of practice.

Nice To Haves

Bachelor’s degree in nursing (BSN).
Five years of clinical nursing experience.
Experience in healthcare quality improvement, infection prevention, employee health, or risk management.
Experience in a Critical Access Hospital or rural healthcare setting.
Knowledge of CMS Conditions of Participation and applicable healthcare regulatory requirements.
Certification in Infection Control (CIC).
Certified Professional in Healthcare Quality (CPHQ).

Responsibilities

Coordinate and manage the organization-wide QAPI program and annual quality improvement plan in accordance with applicable regulatory requirements.
Collect, validate, analyze, and report inpatient and outpatient quality measures, including required CMS, MBQIP, eCQM, Nebraska Hospital Association, and other program reporting.
Monitor quality indicators and outcomes; facilitate Quality Council meetings; prepare reports for executive leadership, the Board of Directors, and medical staff; and coordinate peer review support with Health Information Services.
Work with department managers to set improvement goals, facilitate initiatives using methods such as PDSA and root cause analysis, track corrective action plans, and evaluate results.
Maintain documentation of QAPI activities, measures, and improvement outcomes, and provide related education and guidance.
Coordinate, implement, monitor, and evaluate the organization-wide infection prevention and control program; conduct infection surveillance and investigate outbreaks, trends, and exposures.
Collect and report infection prevention data to agencies and systems including NHSN and Nebraska DHHS; develop or review policies; conduct rounds and audits; and coordinate Infection Control Committee activities.
Provide infection prevention training and serve as a resource to employees, medical staff, managers, and collaborating departments.
Coordinate the employee health program, including assessments, pre-employment screenings, immunization and tuberculosis screening services, confidential records, and compliance monitoring.
Assess occupational exposures and coordinate testing, treatment referrals, and follow-up; collaborate on respiratory protection requirements, medical clearances, fitness-for-duty, and return-to-work matters while protecting confidentiality.
Coordinate risk management and patient safety activities; review and investigate reported incidents, adverse events, and near misses; identify trends; and coordinate root cause analyses and other reviews.
Collaborate with managers on corrective actions, monitor their effectiveness, promote incident reporting, identify risks, and communicate significant safety or potential liability concerns to the COO and appropriate leadership.
Monitor patient satisfaction feedback through NRC Health and other systems; identify trends, coordinate follow-up, support complaint and grievance processes, and incorporate findings into improvement work.
Monitor applicable regulations and support survey readiness, required documentation, inspections, corrective action plans, policy updates, and related employee education.
Provide education and training in quality improvement, infection prevention, employee health, patient safety, and risk management; participate in relevant committees and leadership meetings as requested.
Assist with budgets for assigned programs, evaluate supplies and resources, identify efficiency opportunities, and recommend resources or improvements to the COO.
Maintain professional knowledge through continuing education and professional development, and support the organization’s mission, values, and service excellence standards.
Perform other duties as assigned.