Job Objective :

Under the direction of the Manager of Quality and Clinical Safety, this position is responsible for coordinating quality clinical safety activities, as part of the Performance Improvement (PI)/Quality Management (QM) and Clinical Safety (CS)/Risk Management programs (RM). Activities include patient care processes, outcomes, organizational functions, data collection, and regulatory preparation.

Duties and Responsibilities:

Non-Essential Duties:

• Other duties as assigned by the Director of Quality Management, Clinical Safety and Infection Control

Knowledge, Skills and Abilities:

Knowledge

• Current knowledge of QM and CS principles.
• Knowledge of Regulatory and Accrediting bodies such as CMS, JC, State Department of Health and insurance providers.
• Maintains an appropriate level of professional competence by ongoing development of knowledge and skills.

Skills

• Strong communication skills to include group presentations
• Skill and ability to follow the established Customer Service Expectations and Standards
• Computer skills to include data entry. Working knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, and Word)
• Demonstrated expertise in systems analysis and management skills at a minimum of an assistant director level

Abilities

• Ability to work effectively with hospital and medical staff professionals
• Ability to handle patient care concerns with objectivity and professionalism
• Uses current research findings and other evidence to expand knowledge, enhance role performance, and increase knowledge of professional issues.

AVH Values: All AVH employees will effectively demonstrate these values:

• Patients Come First – We listen actively and communicate with our patients and families, placing safety as a top priority.
• Accountability & Ownership – We fully complete tasks, are transparent, effectively communicate, and recognize that what we do reflects on us.
• Teamwork – We build trusting relationships, promote a sense of community, and are respectful of everyone. Success is about the whole team.
• Integrity & Honesty – We tell the truth at all times, speak up when something is wrong, and do the right thing when no one is looking.
• Excellence – We take pride in our work, are goal-oriented, and on a never-ending quest for top tier quality.
• Initiative & Innovation – Our can-do attitudes, creativity, and resourcefulness empower us to improve the patient’s experience, solve our own problems, make timely decisions, and look for opportunities to add value.
• Tenderness & Compassion – We have genuine empathy, show kindness, and encourage and advocate for each other.

Education and Experience:

Education

• BSN required or to be completed within three years.
• MSN or MS equivalent preferred.
• Certification in either Quality or Risk Management desired.

Experience

• Three years’ Clinical experience in Acute Hospital preferred.
• Experience or training in statistical methodologies and data analysis preferred

Required Licensure and/or Certifications:

• Current California Registered Nursing license

AVH Conduct/Compliance Expectations :

• Ability to adhere with AVH Attendance and Punctuality Policy
• Ability to adhere with AVH Leaves of Absence Policy
• Ability to adhere with AVH Paid Time Off (PTO) Policy
• Ability to adhere to the department dress code
• Ability to organize work and establish priorities
• Ability to expand on own initiative in performance of duties
• Skill and ability to follow the telephone etiquette/standards
• Ability to function effectively under pressure and meet time parameters
• Ability to communicate effectively while maintaining good working relationships with co-workers, managers and other hospital staff
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVH
• Ability to maintain the confidentiality of patient, hospital and department information
• Ability to adhere to safety rules and regulations
• Safely and effectively uses all equipment necessary to carry out duties
• Ability to interpret and function under hospital and department policies and procedures
• Conforms with required and appropriate Joint Commission requirements
• Conforms with and supports hospital quality assurance and improvement guidelines
• Ability to participate effectively in department and hospital staff education
• Display a willingness to work as a team player
• Ability to give and support the highest level of patient/customer satisfaction at all times
• Supports and adheres to the values and mission statement established by the AVH Board of Directors
• Ability to demonstrate knowledge and understanding of the Compliance & Integrity Program and its established policies.
• Ability to follow the Code of Conduct

Physical Requirements and Working Conditions:

• Work is often performed under stressful, emotional and physical conditions for the office environment
• Work is performed both in an office and nursing unit environment
• Must be able to make walking rounds and conduct record reviews and/or speak with patient/family as needed throughout the hospital

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

Education

• BSN required or to be completed within three years

Required Licensure and/or Certifications:

• Current California Registered Nursing license