Job description

Summary:

The Quality Assurance Specialist will support the quality team in the development, coordination, and implementation of quality improvement, patient safety and regulatory compliance activities as well as infection prevention and employee exposure processes across all clinics at MHM.

Essential Duties:
Quality/ Process Improvement

• Coordinates, schedules, and organizes activities for quality improvement projects and initiatives.
• Coordinates the review of action items and upcoming agendas for the Quality team.
• Demonstrates knowledge of performance and process improvement methods and quality improvement tools and techniques.
• Remain up to date on all CDC guidelines and definitions of HAI’s, accrediting organization standards, federal and state regulations and national guidelines.
• Collaborate with leadership and healthcare providers responsible for all department infection prevention policies and processes.
• Assist in staff education surrounding all infection control policies and processes.
• Maintains the organizational repository for improvement project related documents (project artifacts).
• Collaborates with decision support and improvement teams in the collection of data relevant to metrics and improvement projects.

• Investigation into potential opportunities for improvement through chart audits and data analysis.

• Collaborates with Quality and Patient Safety Director in the monitoring of identified clinical and process measures for improvement opportunity and control of improved processes.
• Participates in the facilitation of designated quality performance and improvement initiatives across the organization.

Compliance

• Actively monitors and communicates changes to relevant regulatory infection prevention standards.
• Compiles evidence-based research on designated topics such as regulatory compliance standards and clinical practice models to inform team initiatives and projects.
• Protects confidentiality of privileged information in accordance with applicable legal and regulatory requirements.
• Assists in the development, and regular review of MHM’s quality, patient safety and compliance policies and procedures.

• Collaborates with team members in the development of compliance action plans in response to survey/review findings
• Actively participates in interdepartmental committees, as appointed, such as HIPAA, Safety and Environment of Care, Infection Prevention and Control

Patient Safety

• Supports the Quality team in monitoring patient safety incidents and assists with investigations.
• Participates in the facilitation of root cause analysis teams and ensures follow-up of resulting action items.
• Tracks, analyzes and trends patient safety incidents to identify areas for improvement.
• Organizes and maintains documents related to safety/compliance incidents and the corresponding assessments and follow up plans.
• Participates in the development of regular patient safety incident and RCA summary reports for presentation to leadership.
• Ensures compliance with all state disease reporting requirements.
• Performs other duties as assigned

Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:
Bachelor of Science degree in Nursing or other health related discipline is required. Graduate degree in related field (i.e. MBA, MSN, MHA) preferred. Certified Infection Control preferred. Two (2) years of clinical, quality, infection prevention or regulatory experience preferred.

Experience or training in principles of quality improvement and regulatory compliance preferred. Strong analytical and critical thinking skills and experience in utilizing work processing, spreadsheets, and clinical systems/databases preferred.

Language Ability:
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to read, analyze medical documents. Fluent in English, both verbal and written required.

Reasoning Ability:
Ability to define problems, collect data, establish facts, and draw valid conclusions. Ability to interpret a variety of technical instructions furnished in mathematical or diagram form and deal with several abstract and concrete variables.

Certificates and Licenses:
Certification as a Certified Professional in Healthcare Quality (CPHQ) preferred. Any other healthcare quality or compliance certification preferred.

Computer Skills:
To perform this job successfully, an individual should have knowledge of internet, Outlook, PowerPoint, Word processing software and Excel and Access software.

Work Environment and Physical Demands:
The work environment characteristics described here are representative of those a team member encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the team member is exposed to a medical office environment having direct contact with patients and clients. Position necessitates bending, stooping, twisting, turning, walking, climbing step stools, sitting and standing for periods of time. Must be able to lift and maneuver 25 pounds.

Job Type: Full-time

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