Job Summary:

The Quality Improvement Coordinator will manage the development, implementation, and evaluation of the hospital's overall quality improvement (QI) program that includes ancillary, nursing, and medical staff departments to identify trends, prioritize and recommend improvements, decrease duplication, and ensure Joint Commission on Accreditation of Healthcare Organizations (JCAHO) compliance. The Quality Improvement Coordinator will also investigate incident reports, patient complaints, patient care issues, and other issues as requested by the supervisor.

Supervisory Responsibilities:

• None.

Duties/Responsibilities:

• Works with medical staff department chairpersons on peer review activities.
• Coordinates the development, implementation and revision of the medical staff's QI program to meet the needs of patients, staff, and external agencies.
• Provides QI leadership and consultative services to hospital and medical staff in effectively achieving regulatory accreditation and organizational compliance for QI activities.
• Organizes, compiles, and reports QI data for both the hospital and medical staff departments to identify trends, establish priorities, and recommend improvement activities.
• Performs comprehensive, concurrent, and retrospective reviews in a timely manner, using criteria developed and approved by the medical staff and the hospital.
• Reports findings to other departments such as utilization review, infection control, and risk management.
• Serves as a working member of the hospital's quality council; attends medical staff department and committee meetings and other pertinent meetings to ensure the organization's overall QI plan implementation and compliance.
• Keeps abreast of current JCAHO standards and other accreditation standards, and the latest quality techniques in health care.

Required Skills/Abilities:

• Demonstrated initiative, ability to work with others, and good professional judgment.
• Ability to work independently and organize time effectively.
• Excellent written and verbal communication skills.

Education and Experience:

• An RN degree required.
• State nursing license required.
• A least three years of clinical nursing experience with one year in medical/surgical nursing preferred.

Physical Requirements:

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift up to 15 pounds at times.