Quality and Compliance Coordinator - PRN - Days
Description
Job Description:
Formulated:
05/2017
Quality and Compliance Manager
Department:
Reviewed by Senior Human Resources
Business Partner:
05/2017
Nursing Administration
Reports To:
Approved by Director of Human
Resources:
05/2017
Chief Nursing Officer
EMPLOYEE’S FULL NAME: ________________________
FLSA STATUS: ☒ Non-Exempt
MISSION STATEMENT:
Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every
encounter, every time.
VISION:
Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve
by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.
POSITION SUMMARY:
The Quality and Compliance Coordinator is responsible for providing project management and facilitation, as well as,
oversight and support for the development, coordination, implementation and evaluation of quality improvement and
patient safety initiatives. The Quality and Compliance Coordinator reports to the CNO. Quality and Compliance
Coordinator assists with management of the database used for quality tracking and improvement efforts. The Quality
and Compliance Coordinator is responsible for maintaining the scorecards and other reports used for Quality
Improvement. He/she assists in maintaining compliance with requirements of external agencies in the area of quality
and accreditation surveys/inspections, specifically those related to The Joint Commission, CMS, UNOS, and the ESRD
Network.
POSITION EDUCATION/ QUALIFICATIONS:
•
Bachelor of Science degree in Nursing or other relevant discipline required; Master’s Degree in Nursing,
Health Care, Public Health or Business Administration preferred.
•
•
Strong analytical, problem solving, and quantitative skills
Excellent interpersonal skills, including the ability to establish and maintain effective relationships with
patients, physicians, management, staff, peers, and other customer.
•
Demonstrated customer service skills, including the ability to use appropriate judgment, independent
thinking and creativity when resolving issues.
•
•
Excellent verbal and written communication skills.
Computer skills: Word, Excel, PowerPoint, clinical documentation systems.
DISCLAIMER
The above statements are intended to describe the general nature and level of the work being performed by people assigned to
this work. This is not an exhaustive list of all duties and responsibilities. DHR leadership reserves the right to amend and
change responsibilities to meet business and organizational needs as necessary.
Job Description:
Formulated:
05/2017
Quality and Compliance Coordinator
Department:
Reviewed by Senior Human Resources
Business Partner:
05/2017
Nursing Administration
Reports To:
Approved by Director of Human
Resources:
05/2017
Chief Nursing Officer
JOB KNOWLEDGE/EXPERIENCE:
•
•
•
Experience in quality assurance and performance improvement activities preferred
Certification in quality improvement preferred
Supervisory/management experience preferred
POSITION RESPONSIBILITES:
• Coordinates Performance Improvement Activities
o
o
o
Assures continuous tracking of quality data in databases, monitors ongoing data integrity processes
Coordinates development and preparation of quality report cards/scorecards
Coordinates with the medical and surgical directors the regular reporting of quality data to the appropriate
hospital committees. Prepares or assists with the presentations for those meetings.
Organizes and facilitates multi-disciplinary teams to successfully implement performance improvement
initiatives to achieve program quality improvement goals
Annually coordinates a review of the PI indicators defined for each program and makes recommendations
for revisions.
Oversees the ongoing medical record reviews, including reviews of documentation required for UNOS,
TJC and CMS. Collates and submits data related to these reviews to the leadership team and hospital
departments as requested.
o
o
o
•
Facilitates and coordinates accreditation and regulatory compliance
o
o
o
o
o
Maintains current knowledge of requirements related to CMS Conditions of Participation, Joint
Commission, and UNOS.
Provides regular updates to managers and ongoing education to staff as requested by the
management staff.
Responsible for supporting management staff to achieve and maintain accreditation and regulatory
compliance. Assists in the preparation of action plans.
Prepares and maintains materials/documents used for surveys by CMS/NC Dept of Health for
transplant centers and for Joint Commission.
Assists managers and staff to assure continuous readiness for survey with policy and procedure review
and revision, mock survey drills, and ongoing education.
DISCLAIMER
The above statements are intended to describe the general nature and level of the work being performed by people assigned to
this work. This is not an exhaustive list of all duties and responsibilities. DHR leadership reserves the right to amend and
change responsibilities to meet business and organizational needs as necessary.
Job Description:
Formulated:
05/2017
Quality and Compliance Coordinator
Department:
Reviewed by Senior Human Resources
Business Partner:
05/2017
Nursing Administration
Reports To:
Approved by Director of Human
Resources:
05/2017
Chief Nursing Officer
o
o
Coordinates scheduling of un/announced visits/surveys.
Coordinates preparation of UNOS reports including annual personnel report, changes in key personnel,
and reports requested by the Membership and Professional Standards Committee.
Monitors and tracks compliance with UNOS requirements for data submission. Alerts the management
team if there is not full compliance with the requirements.
o
LINES OF REPSONSIBILITES:
(Chain-of-command)
1. Chief Nursing Officer
CUSTOMER SERVICE:
Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program
which outlines the Customer Service Principals including: Compassion, Accountability, Respect, Excellence through
Knowledge and Safety & Social Conscience.
AGE SPECIFIC:
Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the
patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and
development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the
appropriate information needed to identify each patient’s requirement relative to his or her age.
AMERICANS WITH DISABILITIES ACT: (ADA):
A.
Essential Duties:
Indicated by bold print within performance standards, preceding individual numbered
criteria.
The following table provides physical requirements that will be associated with, but not limited to, this position:
DISCLAIMER
The above statements are intended to describe the general nature and level of the work being performed by people assigned to
this work. This is not an exhaustive list of all duties and responsibilities. DHR leadership reserves the right to amend and
change responsibilities to meet business and organizational needs as necessary.
Light/moderate lifting up to 20 lbs, from the Yes
floor to shoulder height.
Kneeling
Yes
Yes
Yes
Must be able to assist other employees with
lifting more than 20 lbs.
Yes
Walking
Light/moderate carrying up to 20 lbs.
Yes
Standing/Squatting
Job Description:
Formulated:
05/2017
Quality and Compliance Manager
Department:
Reviewed by Senior Human Resources
Business Partner:
05/2017
Nursing Administration
Reports To:
Approved by Director of Human
Resources:
05/2017
Chief Nursing Officer
Straight pulling
Pulling hand over hand
Repeated bending
Reaching above shoulder
Simple grasping
Dual simultaneous grasping
Ability to see
Operating office equipment
Operating mechanical equipment
Ability to read and write
Ability to hear verbal communication
without aid
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Sitting
Pushing
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Stooping/Bending
Climbing Stairs
Climbing Ladders
Depth Perceptions needed
Identify Colors
Twisting
Crawling
Ability to Count
Operating Personal Vehicle
Yes
Yes
Ability to comprehend written/verbal
communication
OSHA Category
Yes
III
Other: Ability to deal with stress
Yes
B.
C.
Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with
varying exposures to noise. There is protection from weather conditions but not necessarily from temperature
changes. The position does have low exposure to malodorous, infectious body fluids from patients and some
minimal exposure to noxious smells from cleansing agents.
Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an
OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might
encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their
employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other
way.
D.
Aptitudes:
HIGH
1
2
3
4
5
6
LOW
DISCLAIMER
The above statements are intended to describe the general nature and level of the work being performed by people assigned to
this work. This is not an exhaustive list of all duties and responsibilities. DHR leadership reserves the right to amend and
change responsibilities to meet business and organizational needs as necessary.
Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying
principles. Ability to reason and make judgments. 3
Job Description:
Formulated:
05/2017
Quality and Compliance Coordinator
Department:
Reviewed by Senior Human Resources
Business Partner:
05/2017
Nursing Administration
Reports To:
Approved by Director of Human
Resources:
05/2017
Chief Nursing Officer
Verbal:
Ability to understand meanings of words and ideas associated with them, and to use them
effectively. To comprehend language, to understand relationships between words, and to understand meanings of
whole sentences and paragraphs. To present information or ideas clearly. 3
Numerical:
Spatial:
Ability to perform arithmetic operations quickly and accurately. 2
Ability to comprehend forms in space and understands relationships of plane and solid objects.
Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of
geometric forms. 2
Form Perception:
Ability to perceive pertinent details and objects or in pictorial or graphic material to make
visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and
lengths of lines. 3
Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences
in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2
Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise
movements with speed. Ability to make a movement response accurately and quickly.
3
Finger Dexterity:
motions.
Ability to move hands easily and skillfully. To work with fingers in placing and turning
Ability to move hands easily and skillfully. To work with hands in placing and turning
3
Manual Dexterity:
motions.
3
Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance
with visual stimuli.
3
Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other
values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting
color combinations, or to match color adequately.
3
DISCLAIMER
The above statements are intended to describe the general nature and level of the work being performed by people assigned to
this work. This is not an exhaustive list of all duties and responsibilities. DHR leadership reserves the right to amend and
change responsibilities to meet business and organizational needs as necessary.
Job Description:
Formulated:
05/2017
Quality and Compliance Coordinator
Department:
Reviewed by Senior Human Resources
Business Partner:
05/2017
Nursing Administration
Reports To:
Approved by Director of Human
Resources:
05/2017
Chief Nursing Officer
I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to
perform.
If applicable ____________ certification will be completed within _________ time frame of hire/transfer date.
Employee Signature: ________________________________ Date: ____________________
Transfer/Hire Date Effective: ________________________.
DISCLAIMER
The above statements are intended to describe the general nature and level of the work being performed by people assigned to
this work. This is not an exhaustive list of all duties and responsibilities. DHR leadership reserves the right to amend and
change responsibilities to meet business and organizational needs as necessary.