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Overview

Job Summary

Coordinates implements and evaluates the hospital and medical staff clinical and operational performance improvement activities. Coordinates processes to maintain compliance with regulatory agencies and accrediting bodies. Provides reports, export data, create correspondence, presentations, or other forms of information to support initiatives as directed by the Quality Manager. Reports to Quality Manager. Performs other duties assigned.

Responsibilities

+ Assists in coordinating and evaluating hospital and medical staff performance improvement activities.

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

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

+ Communicates effectively with physicians, staff, and external entities.

+ Data Abstraction for CMS and other regulatory agencies;All quality data (Sepsis, Stroke, Trauma, AMI, etc)

+ Documents trends/practice patterns by providing data from quality monitoring activities.

+ Extender-Employee Health for Baptist Memphis Employee Health:Extender -Infection Prevention for Baptist Memphis Infection Prevention; Manage Flu program, ie: scheduling, administering, maintain records; Respiratory Fit testing, training and maintaining database; EOC rounds; Hand Hygiene

+ Maintains Policies and Procedures

+ Perform day-to-day observations and audits, such as hand hygiene, PPE compliance, EOC issues.

Specifications

Experience

Minimum Required

+ Current RN license and three years clinical experience and/or three years in quality management or accreditation preparation.

Preferred/Desired

+ Five years experience in clinical practice; Five years experience in quality management or accreditation preparation.

Education

Minimum Required

Preferred/Desired

Training

Minimum Required

Preferred/Desired

Special Skills

Minimum Required

+ Skill in communicating clearly and effectively using standard English in written, oral and verbal format to achieve high productivity and efficiency. Skill to write legibly and record information accurately as necessary to perform job duties. Advanced communication, conflict management, organizational and planning skills. Basic computer literacy skills.

Preferred/Desired

Licensure

Minimum Required

+ RN

Preferred/Desired

REQNUMBER: 32407