Summary/Objective:

The Quality Coordinator is responsible for ensuring regulatory compliance within the facility.

Essential Functions:

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

1. Plan, develop, organize, implement, evaluate, and directs the Quality Assurance Department, as well as its programs and activities, in accordance with current rules, regulations, and guidelines that conform to current standards of practice and operational policies while maintaining compliance with state and federal laws and regulations.

2. Develop, maintain, and periodically update quality assurance policies and procedures.

3. Communicates and interprets policies and procedures to hospital staff and monitors staff practices and implementation (related to quality assurance goals).

4. Coordinates quality assurance services with all other departments.

5. Collaborates with physicians, community agencies, and institutions to improve the quality of services and to resolve identified problems.

6. Coordinates and/or develops on-going quality assurance activities for hospital to monitor compliance with standards and regulatory requirements through rounds, interviews, and record reviews.

7. Promotes customer service and hospitality and responds to and adequately resolves concerns, complaints, or grievances from patients or families about quality assurance services.

8. Promotes compliance with accident prevention procedures, safety rules, and safe work practices to prevent employee injury and illness and control workers’ compensation costs.

9. Coordinates and/or develops on-going quality assurance activities for hospital to monitor compliance with standards and regulatory requirements through rounds, interviews, and record reviews.

10. Communicate with department managers regarding problems identified and/or ways to attempt to solve problems.

11. Develop, form, and direct teams through the process improvement process.

12. Educate/teach quality management methodologies to include statistical process control and problem solving utilization flow charts and diagrams.

13. Interacts with Administration, medical staff, Hospital Authority, department directors, and hospital staff as necessary.

14. Aide department managers in the implementation and adherence of the quality management plan.

15. Monitor all problematic studies for follow-up studies and ultimately problem resolution.

16. Identify components of the quality management program that may need to be instituted, altered, or deleted.

17. Complete and manage all minutes from team activities and the quality board committee.

18. Participates in the Partnership for Health and Accountability (PHA) program with total accountability for all required functions to include requesting, receiving, and maintaining peer review information, as well as PHA’s material and reports as necessary.

19. Participate in the Hospital Quality Alliance with total accountability for all required functions to include requesting, receiving, and maintaining quality data for the program and the development of tools to be utilized by the facility to achieve the best quality outcomes.

20. Develop, review/revise, and implement policies and procedures for quality management and risk management.

21. Ensures committee participation and reporting duties for the Environment of Care, Medical Executive, and Medical Staff committees.

22. Develops and manages a risk identification process for the organization’s operations, departments, and services. Educates and assists other managers in assessing their areas of responsibility for exposures of loss and unsafe processes and conditions.

23. Maintains a risk management information system. Collects, evaluates, and reports on events, incidents, and claims. Performs statistical analysis and trending of events and claims to pinpoint high risk areas for management attention.

24. Prepares reports of events as required by law or in accordance with voluntary participation.

25. Assesses hospital compliance with accreditation standards and regulations in collaboration with leadership and staff.

26. Identifies areas of vulnerability related to accreditation standards and regulations with the development of strategies to enhance compliance.

27. Provide direction and support to administration through collaboration with the leadership and staff for activities related to accreditation and regulatory affairs, performance improvement, patient safety including sentinel event response, policy development, clinical documentation, and clinical outcomes.

28. Attend educational seminars, programs, and society meetings relating to regulatory standards, quality management, and risk management.

29. Participate in wide variety of special projects and compile a variety of special reports.

Competencies:

1. Financial Management.

2. Ethical Conduct

3. Leadership

4. Technical Capacity

5. Customer/Patient Focus

6. Teamwork Orientation

Supervisory Responsibility:

This position is responsible for the direct supervision of the all quality assurance staff.

This position’s responsibilities include: interviewing, hiring, and training employees, planning, assigning, and directing work; appraising performance, rewarding and disciplining employees; addressing complaints and resolving problems.

Work Environment:

This job operates in a professional office environment within a healthcare setting. This role requires regular walking to various locations around the hospital. The employee is occasionally exposed to a variety of patient conditions and elements. The noise level is moderate to quiet. Frequent exposures to distressed patients, families, and visitors. This role routinely uses standard office equipment such as computers, phones, copiers, filing cabinets, and fax machines.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear.

Required Education and Experience:

1. Associates degree in Nursing

2. Current, valid certification in the state of Georgia as a Licensed Practical Nurse or Registered Nurse.

3. Current, valid AHA Healthcare Provider training (ACLS & BLS).

4. 1 to 3 three years of quality assurance experience in a hospital setting.

5. Experience in management in hospital environment including working knowledge of principals of Performance Improvement and Risk Management.

Job Type: Full-time

Benefits:

• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Ability to commute/relocate:

• Forsyth, GA 31029: Reliably commute or planning to relocate before starting work (Required)

Experience:

• ISO 9001: 1 year (Required)

Work Location: One location

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