What are the responsibilities and job description for the Manager of Quality, Infection and Risk position at ANDREWS INSTITUTE ASC LLC?
Main Funciton
Contributes to the fulfillment of the organization’s mission and philosophy by assisting in the analysis, implementation, and evaluation of the quality program. Responsible for the progress and maintenance of organization-wide performance-improvement, risk management, and infection control programs.
1. Philosophy
- Supports the facility’s ideology, mission, goals, and objectives
- Performs in accordance with the facility’s policies and procedures
- Follows the facility’s standards for ethical business conduct
- Conducts self as a positive role model and team member
- Recognizes patients’ rights and responsibilities and supports them in performance of job duties
2. General
- Participates in facility committees, meetings, in-services, and activities
- Punctual and comply with attendance guidelines
- Gets along well with all employees and respects the rights of other employees
- Demonstrates resourcefulness, independent thinking and seeks additional challenges and opportunities. Seeks to create new methods, techniques and processes.
3. Communication
- Communicates effectively and professionally with vendors, physicians, coworkers, patients and visitors
- Interacts with others in a positive, professional, respectful, and considerate manner
- Checks and responds to emails in a timely and efficient manner
4. Financial practices
- Uses facility resources appropriately and avoids wasteful practices
- Reports wasteful practices
- Analyzes work area and makes recommendations for potential cost-effective improvements
5. Compliance program
- Assists in the implementation and maintenance of the organization’s adopted compliance program
- Performs according to established compliance policies and procedures
- Keeps facility’s CLIA certification up to date
- Oversees facility Peer Review Program
6. Safety/risk-management program
- Adheres to safety policies and procedures in performing job duties and responsibilities
- Reports observed or suspected safety violations, hazards, and policy/procedure noncompliance to the safety officer or other designated person
- Complete annual education requirements
- Responsible for facility peer review process
- Oversees facility incident reporting program
- Completes and oversees facilities RCA program
- Oversees and completes facility state reporting
- Maintains grievance log and oversees the grievance process in coordination with the DON and Administrator.
7. Professional competence
- Participates in continuing education and other learning experiences
- Shares knowledge gained in continuing education with staff
- Maintains membership in relevant professional organizations
- Seeks new learning experiences by accepting challenging opportunities and responsibilities
- Welcomes suggestions and recommendations
8. Regulatory
- Remains current on all applicable state and federal laws, rules, regulations, professional
- standards and accreditation standards
- Submits required reports on a timely basis
- Develops, interprets and recommends implementation of policies, procedures, regulations, programs and recommended practices to ensure requirements are met
- Completes facility AAAHC application and/or state applications as applicable to include mandated surveys.
- Obtains and maintains access to state and federal quality reporting programs
9. CQI/Performance-improvement program
- Assists in the development and implementation of the organization's adopted performance-improvement program
- Maintains and updates organization-wide performance-improvement programs, policies, and procedures
- Performs according to established performance-improvement policies and procedures
- Contributes to the performance-improvement process and identifies his or her role and contributions upon supervisor's request
- Organizes and participates in committees, educational programs, and performance-improvement activities
- Completes PAC/Quality Committee Agenda
- Ensures monthly and quarterly quality reports are completed
- Assist with review of new item/equipment request
- Contributes to the evaluation of the performance-improvement program and recommends appropriate revisions, if applicable
- Develops effective data collection, organization, and evaluation systems for monitoring the quality of patient care
- Summarizes collected data and reports findings and recommendations in a timely manner to the performance-improvement committee
- Coordinates performance-improvement activities and communicates outcomes to appropriate committees and individuals
- Assists in the evaluation of patient, and medical staff grievances to identify ways to improve patient care and performance standards
- Identifies resources required for the performance-improvement program and submits resource requests to the director of nursing
- Assists in identifying important indicators, establishing thresholds, and setting timeframe for evaluation
- Maintains performance-improvement status log
- Establish a schedule of facility drills and ensure drills are complete per the regulations
- Complete two quality studies a year
- Completes Hazard and Vulnerability Assessment annually
- Ensures facility’s CEMP plan is up to date
- Serves as an educational resource for performance improvement and keeps facility current on state and federal rules and regulations and accrediting-body requirements
- Maintains performance-improvement records in a confidential and organized manner
10. Infection Control
- Be familiar with facility policies and procedures
- Surveillance, prevention, and control of infection to include monthly infection control rounding
- Identify and reduce risk of acquiring and transmitting infections among patients, employees, physicians and other independent practitioners, contract workers, students and visitors
- Coordinate infection control programs and educates staff
- Completes yearly infection control assessment
- Ensures 30 and 90 day infection reports are complete
- Oversees and coordinates with Quality Coordinator annual evaluation of TB on all employees
- Maintain record of exposures, infections tracking and trending, quarterly documentation and reporting to quality Committee and the Governing Board
- Ensures that all personnel/employees comply with infection control policies in conjunction with the Director of Nursing
- Continual monitoring of high risk and problem prone areas.
- Work with staff/employees to analyze the patterns and trends to identify and determine whether a problem or opportunity for improvement exists
Responsibility for Assets
1. Responsible for performance-improvement program reference materials
2. Responsible for all performance-improvement program records/documentation
Qualifications
1. Cooperative work attitude toward co-employees, management, patients, visitors, and physicians
2. Ability to promote favorable facility image with physicians, patients, insurance companies, and general public
3. Ability to make decisions and solve problems
Required
1. Bachelor’s degree in nursing
2. FL RN License
3. BLS/ACLS/PALS
4. Training/experience in performance-improvement/risk-management; certification preferred
5. Training/experience in healthcare
6. Strong ethical and moral character references
7. Language skills adequate for high-level written and interpersonal communication
Preferred
- OR Experience
- ASC Experience
**ANDREWS IS A TOBACCO FREE WORKPLACE**
The Andrews Institute ASC (AIASC) is committed to promoting health, wellness, and disease prevention and to providing a safe, clean and healthy environment to Workforce Members, patients, and visitors. The use of tobacco and tobacco products is a known and established hazard to the health and well-being of tobacco users and can also directly impact nonusers. In addition, the use of tobacco and tobacco products has been shown to decrease employee productivity and efficiency and increase absenteeism. In recognition of these factors, the Andrews Institute ASC will no longer hire tobacco users.
