A Brief Overview Coordinates quality, performance and operational improvement activities to assess and review care/services provided and compliance with organizational and regulatory standards and requirements. Provides ongoing monitoring and evaluation of the level of patient care/organizational services and operations. What you will do Coordinates and provides reporting of quality/performance/operational review activities and issues in accordance with established guidelines.

• Performs studies to assess conformance to specifications, standardization of processes, performance measures, best practice and safety standards.
• Collaborates with assigned Director and Leadership staff to select specific topics for review, such as problem procedures, drugs, high volume cases, high risk cases or other factors.

Assists in establishing review criteria and standards for measuring and monitoring level of care and services and ensuring compliance with hospital, joint commission and regulatory agencies' requirements consistent with patient care policies, procedures, standards of practices, and demonstrated competencies, and with consideration given to risk management, infection control practices, and patient safety practices. Executes the

Review Process:

• Identifies, selects and obtains medical charts/ records for review, applying quality review criteria to collect data, analyze and prepare reports and present for review.
• Performs concurrent review to identify, investigate, and report:
• unexpected outcomes
• risk management or unusual/sentinel events
• infection control information
• variations from expected criteria
• Evaluates workflows to include work queuing, scheduling, operational practices, space design, and layout, inventory and resource management.
• Conducts specific studies of patient/operational processes and compliance with policy/ procedure when complication/unexpected trends appear.
• Assists in establishing priorities and makes recommendations for improvement activities to ensure compliance with standards of practice and joint commission/regulatory requirements.

Assists in implementation of corrective action for non-compliance. Utilizes analytic skills and statistical analysis to aggregate data to assist with the identification of potential problems and patterns, trends, establish priorities and recommend improvement activities. Confers and works collaboratively with nursing/medical/hospital staff in compliance with iRESPECT standards and promoting patient/customer satisfaction to obtain information and resolve problems regarding quality and/or efficiency of patient care and organizational services. Participates in organization's accreditation procedures and responsibilities by reviewing data and/or reports and making recommendations to ensure compliance with joint commission and other regulatory requirements. Provides administrative support for special projects and studies; collects and compiles data, performs statistical analysis and follows-up as requested or needed. Prepares and maintains required reports, records and files for operational, administrative and compliance purposes. Utilizes computer and information systems to enter, format and retrieve data, generate statistics, computations, tables, charts and graphs. Assesses the environment, personnel, internal operations, and processes to determine approaches and practices that will coordinate people, equipment, and materials to achieve quality and efficient operations. Serves as resource and liaison between departments and participates on quality/performance improvement committees to ensure organization's overall PI plan implementation and compliance. Conducts staff in-services, training and orientation on PI processes/tools/techniques and accreditation standards. Maintains professional credentials and education necessary to keep abreast and maintain a current knowledge of clinical/theoretical/performance improvement principles, concepts and techniques, best practices and current trends. Attends continuing education, staff development, and mandatory programs. Bachelor's Degree in Nursing required. Masters' Degree in Nursing, Health Information Management, Healthcare Administration, Operations Management or a related field completed or in progress, Preferred RN

• Registered Nurse
• State Licensure and/or Compact State Licensure Upon Hire Required and CPQH certification Upon Hire Required Minimum 3 years experience OF clinical experience with comprehensive knowledge of quality performance improvement principles. Required and Additional experience and skills may be required based on area of assignment. Required Physical Demands Standing
• Occasionally Walking
• Occasionally Sitting
• Constantly Lifting
• Rarely Carrying
• Rarely Pushing
• Rarely Pulling
• Rarely Climbing
• Rarely Balancing
• Rarely Stooping
• Rarely Kneeling
• Rarely Crouching
• Rarely Crawling
• Rarely Reaching
• Rarely Handling
• Occasionally Grasping
• Occasionally Feeling
• Rarely Talking
• Constantly Hearing
• Constantly Repetitive Motions
• Frequently Eye/Hand/Foot Coordination
• Frequently Regional One Health is an equal opportunity employer.