The Clinical Quality and Patient Safety Coordinator plans, coordinates, implements and evaluates hospital quality/performance improvements, patient safety program and assists in coordinating compliance and regulatory programs for preparedness and accreditation requirements.
Coordinates investigation, analysis and responds to quality/patient safety issues, events, significant care issues or trends. Leads and/or facilitates root cause analysis (RCAs) and Apparent Cause Analyses (ACAs) working with multidisciplinary teams
Develops and analyzes data for leadership and clinical decision making, as well as regulatory requirements. Initiates and oversees performance improvement projects. Serves as a resource and/or facilitates improvement teams to plan, implement and coordinate entity activities to maximize clinical and operational outcomes
Coordinates implementation of data collection processes: provide analysis, research and benchmarking. Prepares and present reports for appropriate facility, system, and other external agencies. Provides oversight to projects including data abstracting and data entry as appropriate.
Performs data abstractions for Core Measures and NJ Stroke Database as needed.
Supports implementation of facility quality and patient safety goals, procedures, and activities designed to meet the requirements of regulatory and accrediting agencies such as TJC, CMS, and NJDOH.
Coordinate peer review activities for physicians and provide information for departmental improvement activities including data for Physician and Allied Health Professional s profiles for reappointment and for OPPE and FPPE regulatory requirements.
Serve as a member on committees and councils as assigned, both internal and external, to ensure the role of performance improvement in all outcomes
Maintains clinical performance assessment, performance improvement, change management and project facilitation expertise through independent study, as well as attending education workshops, reviewing professional publications, and participating in professional societies.
RN with a minimum of 5 years experience in the clinical area preferred
Bachelor s degree in Nursing preferred
Minimum of 2 years of Quality/PI/Patient Safety experience in a healthcare setting required
Certified Professional in Healthcare Quality (CPHQ) or Certified Professional in Patient Safety (CPPS) preferred or able to obtain within 18 months of hire.
Working knowledge of Regulatory Standards (NJDHSS, CMS, TJC, Patient Safety Act Reporting and Sentinel Event/Joint Commission Reporting) required.
Knowledge of Performance Improvement basics required
Some knowledge of/or training in various Performance Improvement databases for internal and external reporting preferred.
Computer experience in Microsoft Office Suite is required
Must be a able to work independently and as a member of a team, be detail oriented with strong analytical and problem solving skills and have the ability to successfully plan, organize and complete assigned projects.