This job collaborates with department managers and committees in the identification, trending and analysis of clinical quality issues and facilitates resolution of these issues in a collaborative fashion.
Plays a key role in accreditation and survey processes within the organization as well as the Advanced Certification Specialty programs, where applicable.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and / or ability required.
Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential duties.
This job description is a summary of the primary duties and responsibilities of the job and position. It is not intended to be a comprehensive or all-inclusive listing of duties and responsibilities.
Contents are subject to change at the company's discretion.
Education
Required - Registered nurse diploma.
Preferred - Bachelors degree in nursing.
Work Experience
Required - 3 years of experience as a professional nurse in an acute care setting.
Preferred - 5 years of experience as a professional nurse in an acute care setting.
Certifications
Required - Current registered nurse (RN) license in the state of practice.
Knowledge Skills and Abilities (KSAs)
Proficiency in using computers, software, and web-based applications.
Effective verbal and written communication skills and ability to present information clearly and professionally to varying levels of individuals throughout the patient care process.
Knowledge of regulatory and accrediting standards.
General knowledge of quality management and continuous quality improvement.
Ability to work a flexible work schedule (e.g. 24 / 7, weekend, holiday, on call availability) and travel throughout and between facilities.
Job Duties
Conducts report analysis on occurrences, outcomes and other indicators.
Participates in various organization committees and councils to provide data analysis, trended reports and direction for performance improvement initiatives.
Provides education to the organization related to performance improvement, clinical patient safety and statistical analysis.
Acts as a resource to the organization for all regulatory requirements, including conducting regularly scheduled Joint Commission Mock Surveys and facilitates organizational continued Joint Commission readiness.
Participates in risk management through the identification, trending and follow up of clinical issues.
Adapts behavior to the specific patient population, including but not limited to respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style.
Performs other related duties as required.
The above statements describe the general nature and level of work only. They are not an exhaustive list of all required responsibilities, duties, and skills.
Other duties may be added, or this description amended at any time.
Remains knowledgeable on current federal, state and local laws, accreditation standards or regulatory agency requirements that apply to the assigned area of responsibility and ensures compliance with all such laws, regulations and standards.
This employer maintains and complies with its Compliance & Privacy Program and Standards of Conduct, including the immediate reporting of any known or suspected unethical or questionable behaviors or conduct;
patient / employee safety, patient privacy, and / or other compliance-related concerns.
The employer is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or disability status.
Physical and Environmental Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Medium Work - Exerting 20 to 50 pounds of force occasionally, and / or 10 to 25 pounds of force frequently, and / or greater than negligible up to 10 pounds of force constantly to move objects.
Constantly : activity or condition exists 2 / 3 or more of the time) to move objects. Physical demand requirements are in excess of those for Sedentary Work.
Even though the weight lifted may be only a negligible amount, a job should be rated Light Work : (1) when it requires walking or standing to a significant degree;
or (2) when it requires sitting most of the time but entails pushing and / or pulling of arm or leg controls; and / or (3) when the job requires working at a production rate pace entailing the constant pushing and / or pulling of materials even though the weight of those materials is negligible.
NOTE : The constant stress and strain of maintaining a production rate pace, especially in an industrial setting, can be and is physically demanding of a worker even though the amount of force exerted is negligible.
Duties performed routinely require exposure to blood, body fluid and tissue.
The incumbent works in a patient care area; works in an area where patients enter; works directly with patients; and / or works with specimens that could contain diseases.
There may be an occupational risk for exposure to all communicable diseases.
Because the incumbent works within a healthcare setting, there may be occupational risk for exposure to hazardous medications or hazardous waste within the environment through receipt, transport, storage, preparation, dispensing, administration, cleaning and / or disposal of contaminated waste.
The risk level of exposure may increase depending on the essential job duties of the role.