Job Description
Job Description
Main Function
Contributes to the fulfillment of the organization’s mission and philosophy by assisting in the analysis, implementation, and evaluation of the facility’s quality and education needs. Responsible coordinating required quality and education items per the facility’s accrediting body and state / federal guidelines.
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 activitiesPunctual and comply with attendance guidelinesGets along well with all employees and respects the rights of other employeesDemonstrates 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 visitorsInteracts with others in a positive, professional, respectful, and considerate mannerChecks and responds to emails in a timely and efficient manner4. Financial practices
Uses facility resources appropriately and avoids wasteful practicesReports wasteful practicesAnalyzes work area and makes recommendations for potential cost-effective improvements5. Compliance program
Assists in the implementation and maintenance of the organization’s adopted compliance programPerforms according to established compliance policies and procedures6. Safety / risk-management program
Adheres to safety policies and procedures in performing job duties and responsibilitiesReports observed or suspected safety violations, hazards, and policy / procedure noncompliance to the safety officer or other designated personComplete annual education requirements7. Professional competence
Participates in continuing education and other learning experiencesShares knowledge gained in continuing education with staffMaintains membership in relevant professional organizations as designatedSeeks new learning experiences by accepting challenging opportunities and responsibilitiesWelcomes suggestions and recommendations8. Regulatory
Remains current on all applicable state and federal laws, rules, regulations, professionalstandards and accreditation standardsSubmits required reports on a timely basisDevelops, interprets and recommends implementation of policies, procedures, regulations, programs and recommended practices to ensure requirements are metAssists with completion of facility’s AAAHC application and / or state applications9. CQI / Performance-improvement program
Assists in the development and implementation of the organization's adopted performance-improvement program / QualitySubmit data to patient satisfaction survey vendorReview trends in patient satisfaction data with Quality Manager and Director of NursingMonitor patient satisfaction reportsAssist with maintaining and updating organization-wide performance-improvement programs, policies, and proceduresPerforms monthly chart auditsAssists with completion of monthly and quarterly quality reportsContributes to the performance-improvement process and identifies his or her role and contributions upon supervisor's requestContributes to the evaluation of the performance-improvement program and recommends appropriate revisions, if applicableAssists with data collection, organization, and evaluation systems for monitoring the quality of patient careSummarizes collected data and reports findings and recommendations in a timely manner to the Quality Manager and performance-improvement committeeCoordinates performance-improvement activities and communicates outcomes to appropriate committees and individualsAssists in the evaluation of patient, and medical staff grievances to identify ways to improve patient care and performance standardsAssists in identifying important indicators, establishing thresholds, and setting timeframe for evaluationServes as an educational resource for performance improvement and keeps facility current on state and federal rules and regulations and accrediting-body requirementsMaintains performance-improvement records in a confidential and organized mannerAssists with facility quality studies as needed10. Education
Serve as a HealthStream administrator for managing required facility educationEnsure all employees are up to date with the required educationStay up to date on education requirements from accrediting bodies, state, and federalComplete monthly Education and Certification ReviewEnsure HealthStream shows current license and employee certificationsAssists with facility drills11. Infection Control
Be familiar with facility policies and proceduresSurveillance, prevention, and control of infectionIdentify and reduce risk of acquiring and transmitting infections among patient, employees, physicians and other independent practitioners, contract workers, students and visitorsCoordinate infection control programs and educates staffAssist with annual evaluation of TB on all employeesAssist with 30 and 90 day infection reportsMaintain record of exposures, infections tracking and trending, quarterly documentation and reporting to quality Committee and the Governing BoardContinual 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 existsResponsibility for Assets
1. Responsible for performance-improvement program reference materials
2. Responsible for all performance-improvement program records / documentation
Required
1. RN degree
2. BLS / ACLS / PALS
6. Strong ethical and moral character references
7. Language skills adequate for high-level written and interpersonal communication
Preferred
Bachelor’s DegreeASC ExperienceOR ExperienceANDREWS IS A TOBACCO FREE WORKPLACEThe 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.
