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Overview

Coordinator-Quality and Accreditation

Job Code:22486

FLSA Status

Job Family: NURSING SUPPORT

Job Summary

Participates in the planning, development, and implementation of goals and objectives related to accreditation, certification, regulatory, federal, and state requirements. Coordinates gathering and distributing of data in support of these clinical and regulatory programs. Conducts portions of the medical staff performance improvement process, including profiling with intent to maintain and improve quality of care and service. Provides consultation to physicians, staff, PI teams, and departments regarding improvement methodologies and processes. Reports to Director of Quality. Performs other duties as assigned.

Job Responsibilities

+ Coordinates, implements and evaluates hospital and medical staff performance improvement activities.

+ Coordinates, implements and evaluates clinical quality initiatives for external comparative benchmarking.

+ Coordinates and facilitates the accreditation and regulatory compliance processes

+ Communicates effectively with physicians, staff, external entities.

+ Educates hospital staff and physicians regarding Performance Improvement tools and techniques.

+ Contributes to preparation for accreditation, certification, and surveys.

+ Complete chart abstraction and data analysis.

+ Assist with development, implementation, and evaluation of quality plan and performance improvement initiatives.

+ Directs community education and prevention programs.

+ Identify trends for strategic planning and performance improvement.

+ Completes assigned goals.

Specifications

Experience

Description

Minimum Required: 5 years of experience in a clinical setting. Prefer previous experience in quality and performance improvement.

Preferred/Desired

Education

Description

Minimum Required

Preferred/Desired

Training

Description

Minimum Required

Preferred/Desired

Special Skills

Description

Minimum Required

Preferred/Desired

Licensure

Description

Minimum Required: Registered Nurse

Preferred/Desired

Reporting Relationships

Does this position formally supervise employees? If set to YES, then this position has the authority (delegated) to hire, terminate, discipline, promote or effectively recommend such to manager.

Reporting Relationships: No

Work Environment

Functional Demands

Label Short Description Full Description

Sedentary Very light energy level Lift 10lbs. box overhead. Lift and carry 15lbs. Push/pull 20lbs. cart

Light Moderate energy level Lift and carry 25-35lbs. Push/pull 50-100lbs. (ie. empty bed, stretcher)

Medium High energy level Lift and carry 40-50lbs. Push/pull +/- 150-200lbs. (Patient on bed, stretcher) Lateral transfer 150-200lbs. (ie. Patient)

Heavy Very high energy level Lift over 50lbs. Carry 80lbs. a distance of 30 feet. Push/pull > 200lbs. (ie. Patient on bed, stretcher). Lateral transfer or max assist sit to stand transfer.

Functional Demands Rating: Light

Activity Level Throughout Workday

Physical Activity Requirements – Sitting: Frequent

Physical Activity Requirements – Standing: Occasional

Physical Activity Requirements – Walking: Occasional

Physical Activity Requirements - Climbing (e.g., stairs or ladders): Occasional

Physical Activity Requirements - Carry objects: Occasional

Physical Activity Requirements - Push/Pull: Occasional

Physical Activity Requirements – Twisting: Occasional

Physical Activity Requirements – Bending: Occasional

Physical Activity Requirements - Reaching Forward: Occasional

Physical Activity Requirements - Reaching Overhead: Occasional

Physical Activity Requirements - Squat/Kneel/Crawl: Occasional

Physical Activity Requirements - Wrist position deviation: Occasional

Physical Activity Requirements - Pinching/fine motor activities: Occasional

Physical Activity Requirements - Keyboard use/repetitive motion: Frequent

Physical Activity Requirements - Taste or smell: Occasional

Physical Activity Requirements - Talk or hear: Frequent

Sensory Requirements

Color Discrimination: Yes

Near Vision: Accurate

Far Vision: Accurate

Depth Perception: Moderate

Hearing: Moderate

Environmental Requirements - Blood-Borne Pathogens: Anticipated

Environmental Requirements – Chemical: Anticipated

Environmental Requirements - Airborne Communicable Diseases: Anticipated

Environmental Requirements - Extreme Temperatures: Not Anticipated

Environmental Requirements – Radiation: Not Anticipated

Environmental Requirements - Uneven Surfaces or Elevations: Not Anticipated

Environmental Requirements - Extreme Noise Levels: Not Anticipated

Environmental Requirements - Dust/Particular Matter: Not Anticipated

Environmental Requirements - Other

REQNUMBER: 31707