Coordinates quality, accreditation, regulatory and licensing (AR&L), patient safety and risk management activities for the medical center. Provides clinical, educational, consulting, and coordinating support to assigned areas. Uses nurses licensure as a substantial amount of scientific knowledge or technical skill for indirect patient care services that ensure the safety, comfort, personal hygiene, and protection of patients; and the performance of disease prevention and restorative measures.
Acts as a consultant for quality, AR&L, risk, patient safety, and infection prevention activities and programs.
Assists with quality management studies through data collection, data input and report development.
Analyzes, interprets and provides recommendation based on quality principles.
Organize and coordinate project planning, group process facilitation, training, and appropriate application of information technology.
Reports all occurrences which may lead to medical center liability and follows up as necessary.
Facilitates interdisciplinary collaboration for implementation of evidence based guidelines, criteria and other clinical tools to reduce variation in clinical practice and to optimize clinical outcomes.
Educates physicians and staff regarding regional projects or regulatory reviews, i.e. the interpretation of regulatory requirements and the methods of compliance when preparing for a review or the interpretation of project goals.
Analyzes risk management/patient safety principles and provides recommendations for the incorporation of risk management principles in each medical center.
Provides support services to appropriate medical center staff in implementing risk management principles into credentialing processes.
Participates in special projects as assigned, such as statistical reports for state, federal, and local agencies.
Applies the appropriate performance improvement methodology to address improvement opportunity (eg. MFI, Lean DMAIC).
May support infection prevention and control activities.
Supports maintenance of IC records and policy/procedure manual reviews and revisions.
Supports the medical centers continuous survey readiness program to maintain compliance with regulatory standards.
Minimum three (3) years of combined experience in quality, risk management, patient safety, infection prevention, accreditation/regulation, licensing or operational clinical leadership in a healthcare setting.
Bachelors degree in nursing, business administration, economics, health care administration, operation research, public health administration, or other related field.
License, Certification, Registration
Registered Nurse License (California) required at hire
CIC certificate required within a year, if primary job focus is Infection Control.
Must be able to work in a Labor/Management Partnership environment.
Minimum of three (3) years experience working in quality operations in an acute care setting.