Quality Assurance RN -- CORPORATE NURSING -- Stonewall Jackson Memorial Hospital

Job Summary

The Quality Assurance RN is responsible for hospital wide identification, collection, analysis and reporting of data and information to foster a culture of continuous improvement.

Under the direction of the Director of Quality, in collaboration with medical and hospital staff, the Quality Assurance RN will facilitate and support an organizational culture of service quality. This will include development, implementation, and evaluation of a long-range plan for improving and/or managing highly positive patient, visitor, employee, and physician relations throughout Mon Health Stonewall Jackson Memorial Hospital. The Quality Assurance RN will advocate for patients by collaborating effectively to respond to costumer issues and/or concerns, communicate interdepartmentally to improve service quality, and innovate with creative reward and recognition strategies for employee engagement. They will also manage patient feedback, ensuring timely follow-up consistent with the CMS requirements. This role will oversee the facility’s employee vaccine program, including the annual influenza vaccination program. Additionally, the QA RN will work in conjunction with Infection Prevention to ensure compliance with FIT testing requirements for the facility’s employees.

Responsibilities

Oversees vender selection and implementation of abstraction tools. Directs and coordinates the activities of Performance Information including: Managing the Performance Information systems utilized by the hospital; Abstracting data; Submitting data; Analysis of data.Submits data for Joint Commission, Premier, Quality Projects, CMS, Hospital Quality Alliance, NRCPR and other databases as required to maintain certification and meet requirements for optimal reimbursement of services provided. Maintains contracts and agreements with Joint Commission, Premier, CMS, Hospital Quality Alliance and other Performance Information databases. Keeps current on requirements for databases and educates hospital staff on changes. Develops and maintains scorecards for Councils. Oversees vendor selection and implementation of abstraction tools used by the Quality Department. Develops and maintains scorecards for Performance data. Participates as a member of hospital wide councils, such as: Environment of Care, Patient Care Council, Pediatric Patient Council and others as needed. Makes periodic environmental/safety/compliance rounds.Assists the Director to assure compliance with Joint Commission. Assists the Director to assure compliance with Joint Commission. Responsible for providing data query, analysis expertise to drive improvement activities, ensuring that data is accurate, meaningful and easily interpreted. Abstracts clinical data from the patient’s medical record and from other databases for submission and/or analysis. Reviews blood utilization, returns to surgery, readmissions, appropriateness of procedure and documentation. Prepares reports and completes follow-up. Submits data for CMS, Premier, Joint Commission, Maryland Indicator Project, State Health Department and other regulatory agencies. Meets deadlines for data submission. Coordinates and conducts organization-wide audit activities. Appropriately leverages others to assist. Collects information and produces statistical and qualitative reports. Disseminates information to appropriate audience and/or senior leaders. Designs reports and graphs that accurately and efficiently represent quality outcomes, and ensures data integrity. Develops and implements spreadsheet/database systems for quality improvement functions. Enters data into specific databases, ensures data accuracy, and questions absence of required data elements. Reports data to appropriate internal and external customers, and assists with interpretation of reports. Reports data to appropriate internal and external customers, and assists with interpretation of reports. Assesses level of understanding and effectively tailors education style that meets individualized, team, and organization needs. Serves as medical staff resource. Is available and, when requested, attends other departments' team meetings to present education and/or inservices. Develops curriculum and teaching materials as appropriate. Assesses level of understanding and effectively tailors education style that meets individualized, team, and organization needs. Collaborates with the Education Department to design and implement education modules for new employee orientation and continuing education. Develops and presents performance reports to Hospital Councils, Medical Staff, Quality Council and the Board of Directors. Serves as a resource within the organization for the process improvement and assessment practices including those related to accreditation by Joint Commission and other agencies. Conducts routine research of the best practices and benchmarks applicable to performance. Supports and promotes organization's Quality initiatives. Understands the concept of, and is committed to, the organization's Mission by demonstrating behaviors consistent with the belief statements. Commits to self-directed growth, e.g., computertraining, continuing education. Serves as a team facilitator or member on Quality Improvement teams as requested. Actively participates on organizational committees; positively represents the department, speaking up and constructively contributing to the discussion and taking on extra work from the committee. Serves on a minimum of one council/committee in the role of liaison. Develops and implements unit-based Process Improvement activities. Is knowledgeable and able to assist in all areas of the Quality department. Takes the initiative to step in and assist coworkers with work while managing to accomplish own duties accurately and in a timely manner. Effectively manages competing priorities. Maintains well-designed and well-organized files (paper and computer), making it easy to quickly retrieve information. Assists the Director in the preparation, compliance and education of staff for continuous readiness for surveys by Joint Commission and other agencies. Attends mandatory in-services, staff meetings, and actively participates in self-education. Completes all required competency assessments on time. Maintains required job knowledge (e.g. licensure and credentials, continuing education etc.). Performs other duties as required.

1. Facilitates resources and administration for annual flu vaccination program. Provides data to Employee Health and Quality for reporting to regulatory entities.

2. Administers other vaccinations programs as directed by Employee Health, as required by policy.

3. Conducts organization’s annual fit testing.

4. Maintains current knowledge by reading professional literature, committee participation and continuing education.

5. Attends committee meetings, staff meetings, and actively participates in self-education.

6. Directs and coordinates the activities of Performance Improvement.

7. Data Abstracting and Analysis

8. Education/Teaching

9. Performs other duties as required/assigned.

Knowledge, Skills & Abilities

Three years (3) experience in hospital setting with experience/knowledge of Quality preferred. Knowledge of Microsoft Office applications (Word, Powerpoint, Excel) required. Must demonstrate interpersonal skills, presentation skills, and an ability to work effectively on committees working directly with physicians. Illustrates ability to organize and prioritize responsibilities. Ability to maintain strict confidentiality relative to sensitive information is required.

Light Work: Frequent lifting and/or carrying of objects weighing up to 10lbs with a maximum lifting of 25lbs. Requires good hand-eye coordination and finger dexterity.

Education

Credentials

• Registered Nurse (Required)

Work Schedule: Days

Status: Full Time Regular 1.0

Location: Stonewall Jackson Memorial Hospital

Location of Job: WV:Weston:Stonewall Jackson Memorial Hospital

Talent Acquisition Specialist: Lotoya A. Henry-Ojugbana lotoya.ojugbana@vandaliahealth.org