Quality Specialist - RN

POSITION PURPOSE:

The Quality Specialist plays a key role in supporting the organization’s commitment to excellence in patient care and regulatory compliance. This position will be involved in multiple areas within the Quality Department, including quality and regulatory reporting, performance improvement, patient safety, risk management, emergency preparedness, infection prevention, and compliance. The specialist collects, analyzes, and reports data to identify trends and opportunities for improvement, creates reports and presentations, and helps facilitate new initiatives. Success in this role requires strong critical thinking skills, an appreciation for data-driven decision-making, and the ability to navigate the electronic medical record with confidence. Proficiency in Microsoft Excel and Word is essential, along with effective communication and collaboration skills to work across multiple departments and support ongoing quality and safety initiatives.

QUALIFICATIONS:

• Graduate from an approved school/college of nursing
• Currently licensed as a Registered Nurse license in the State of Nebraska
• Bachelor’s degree in nursing preferred
• One year experience in rural health nursing preferred
• Attainment or progress toward CPHQ certification within five years

GENERAL REQUIREMENTS:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The requirements listed below are representative of the knowledge, skill, and / or ability required:

• Ability to add, subtract, multiply, and divide
• Ability to generate, read, interpret, and take action as it relates to basic financial statements, national and state regulations, safety rulings, operational and maintenance and organizational policies / procedures
• Ability to write reports and correspondence
• Ability to effectively present information to patients, families, employees, health care providers, etc...
• Ability to work cooperatively and communicate effectively to maintain good working relationships with staff and health care providers
• Ability to work with skill in identifying problems; making frequent decisions regarding method of performance

EQUIPMENT, TOOLS, MATERIALS:

• Calculator
• Computer and printer
• Fax and copy machine
• General office materials/supplies
• Information Systems
• Telephone system

SECURITY/ACCESS:

• Will have access to the facility 24 hours a day.
• Will have access to confidential information abiding by the organizations privacy policies and regulations concerning this information.

Essential Job Duties and Responsibilities:

1. Assists in emergency preparedness coordination

• Assist in preparation of plans that outline operating procedures to be used in response to disasters or emergencies, such as tornadoes, nuclear accidents, and active shooter threats, and in recovery from these events.

• Maintain and update all resource materials associated with emergency preparedness plans.

• Keep informed of federal, state, and local regulations affecting emergency plans and ensure that plans adhere to these regulations.

• Organize drills and coordinate after action reports.

2. Assists in the coordination of the Quality Assurance and Improvement Program at Fillmore County Hospital.

• Serves as a resource for department managers in the area of process improvement and assists with the development of quality improvement projects
• Utilizes process improvement methodology such as Plan-Do-Study-Act and other Process improvement tools and approaches to improve outcomes.
• Collects, reviews, trends, and communicates various outcome measures, such as CMS core measures.
• Performs chart audits to identify potential quality of care issues and reports to the Director of Quality.
• Investigates concerns, trends, or risk factors that present risks to patients of FCH.
• Tracks defined data-sets such as (falls, medication errors, social determinants of health, critical care issues, etc.)
• Researching and assist in developing quality improvement programs to provide services that lead to better healthcare outcomes.

3. Investigates potential and reported areas of risk management

• Recommends and coordinates the implementation of appropriate changes in collaboration with the Director of Quality.
• Evaluates the effectiveness of prevention and control measures.
• Assists with policy software administration
• Assists department managers with policy creation.
• Participates or leads chart review and root cause analysis in collaboration with the Director of Quality.
• Facilitates event reporting and review

4. Support survey readiness through participation in annual reviews, mock surveys, and corrective action plans as directed by the Director of Quality

5. Assists with FCH infection prevention program

• Identifies, analyzes, and develops prospective and retrospective surveillance strategies for nosocomial and community acquired infections to prevent transmission, detect epidemics, and reduce risk in collaboration with the Director of Quality.

• Operates the infection surveillance system according to established protocols and uses statistical techniques to describe, interpret data, and evaluate the significance of the findings.
• Keeps track of surveillance activities and prepares statistical reports from collected data to identify and analyze trends of infections.
• Coordinates implementation of infection control policies and regulations regarding bloodborne pathogens.
• Uses necessary resources, communicates recommendations, and evaluates outcomes of established action plans.
• Reviews, analyzes, and applies standards or guidelines of professional organizations and regulatory and governmental agencies.
• Participates in the annual evaluation of the effectiveness of the infection control and hospital quality program with the development of corrective actions plans, if indicated.

6. Submits quality data to local, state, and national programs in collaboration with the Director of Quality

7. Follows HIPAA regulations and ensures that the confidentiality of patients medical, personal, financial records, employee records, and organizational records is maintained.

8. Participates in FCH committees, quality assurance, performance and quality improvement initiatives, and activities which support the facility and department operations.

9. Complies with the state and federal regulatory requirements related to the performance of FCH operations and requirements of the FCH Compliance Program. Including but not limited to:

• The Compliance Policy.
• Completes all on-line training annually and as assigned.
• All department and organization-wide policies.
• Considers the impact of regulations such as Critical Access Hospital requirements, along with Federal and State of Nebraska regulations and discusses concerns appropriately to ensure compliance.

10. Presents self in a professional manner and enhances professional growth and development through participation in education programs, current literature, in-service meetings and workshops.

• Seeks opportunities for continued growth and performance improvement.
• Always maintains a professional appearance and manner.
• Dependable and completes work in a timely manner.
• Demonstrates an understanding and emphasis on quantity, quality and knowledge of duties and tasks.

11. Performs other duties as assigned.

Essential Standards of Service Excellence:

1. Abides by Fillmore County Hospitals Standards of Professional Courtesy and Respect which include:
   • Communication & Interaction
   • Customer Service & Respect
   • Teamwork
   • Telephone Communication
   • Safety, Pride &Ownership
   • Professional Appearance
2. Abides by Fillmore County Hospitals Core Values 1-12 which include:
   • Authenticity
   • Integrity
   • Awareness
   • Courage
   • Perseverance
   • Faith
   • Purpose
   • Vision
   • Focus
   • Enthusiasm
   • Service
   • Leadership

ESSENTIAL WORK ENVIRONMENT & PHYSICAL REQUIREMENTS:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.