- Under the direct supervision of the Director of Quality, the coordinator supports the overall Quality programs, as assigned, across the continuum of care at DHR. The coordinator is responsible for participating in short-term and long-term strategies to ensure the organization’s mission, vision, and values are carried out through the delivery of high quality, cost effective patient care with a high level of integrity. POSITION EDUCATION/ QUALIFICATIONS :
- Current Texas Registered Nursing license required, BSN preferred
- Minimum experience of three (3) years of accreditation/quality experience in a hospital setting preferred
- Experience in coordinating TJC survey preparation and participation in TJC, State, and CMS surveys within the last three (3) years preferred
- Computer skills required with proficiency in Microsoft Office Suite
- Effective written and verbal communication skills required
- Bilingual – English/Spanish preferred
- Current valid driver’s license required
- Current BLS certification or within the first 90 days of hire JOB KNOWLEDGE/EXPERIENCE : Three (3) years of certification or accreditation experience in the acute healthcare setting preferred Strong organizational, interpersonal, management, and leadership skills
POSITION RESPONSIBILITES: Work collaboratively with hospital and medical staff to achieve transformational change Use high level of organizational skills to manage assignments Responsible for patient education, including, but not limited to 1:1 teaching, classes, development and utilization teaching materials Work with multidisciplinary teams to draft, revise, and enforce policies and procedures in accordance with the mission, vision, regulations and standards Provide education to the hospital and medical staff around certification/accreditation initiatives Develop and implement, in conjunction with marketing and other leaders, a community outreach program that includes, but not limited to, health fairs, physician education, local community events, education events, and speaking engagements Conduct audits, data abstraction, and chart reviews as assigned and input information into appropriate software or tool Develop, manage, facilitate, monitor, and assess quality metrics required by national organizations and evidence-based practice for optimal clinical outcomes and ensure compliance with all activities required to achieve and maintain a disease-specific certifications/accreditations as assigned Conduct daily rounds on inpatients to ensure desired patient outcomes and coordinate care issues with the physician(s) and other members of the interdisciplinary team Work closely with nursing and case management concerning patient and caregiver education and discharge planning Work in partnership with nursing and other team members to develop strategies to improve patient experience scores to meet or exceed established goals Work in conjunction with clinical educators and nursing staff to ensure competency and understanding of the needs of the patient Act as a resource to patient care staff and provide timely feedback to stakeholders Ensure physician satisfaction by developing relationships and following through with problem resolution, recognition and performance improvement, including regular visits with physician's office, if needed Track measures, generate and disseminate reports to stakeholders throughout the care continuum, with the inclusion of patient satisfaction, patient outcomes, and process metrics while identifying areas that require improvement, in order to provide key statistics and outcomes data to hospital leadership and committee meetings Assist department managers with preparation for various committee presentations Develop and analyze data to identify trends, develop action plans, and implement program modification to improve performance Facilitates multidisciplinary team meetings affiliated with assigned programs in partnership with physician members and hospital leadership Strives for evidenced-based practice and demonstrates critical thinking skills to ensure optimal, safe outcomes Participate in regulatory/accreditation/certification surveys as assigned Travel to other hospital locations as needed according to assignments Other duties as assigned Other information: LINES OF REPSONSIBILITES : (Chain-of-command) 1.
Director of Quality → 2. VP of Quality, Safety & Accreditations → 3. Physician Executive 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: Commitment, Accountability, Respect, Excellence and Service. 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.
- 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:
- Light/moderate lifting up to 20 lbs, from the floor to shoulder height.
- Yes
- Kneeling
- Yes
- Must be able to assist other employees with lifting more than 20 lbs.
- Yes
- Walking
- Yes
- Light/moderate carrying up to 20 lbs.
- Yes
- Standing/Squatting
- Yes
- Straight pulling
- Yes
- Sitting
- Yes
- Pulling hand over hand
- Yes
- Pushing
- Yes
- Repeated bending
- Yes
- Stooping/Bending
- Yes
- Reaching above shoulder
- Yes
- Climbing Stairs
- Yes
- Simple grasping
- Yes
- Climbing Ladders
- No
- Dual simultaneous grasping
- Yes
- Depth Perceptions needed
- Yes
- Ability to see
- Yes
- Identify Colors
- Yes
- Operating office equipment
- Yes
- Twisting
- Yes
- Operating mechanical equipment
- Yes
- Crawling
- No
- Ability to read and write
- Yes
- Ability to Count
- Yes
- Ability to hear verbal communication without aid
- Yes
- Operating Personal Vehicle
- Yes
- Ability to comprehend written/verbal communication
- Yes
- Other: Ability to deal with stress
- Yes
- OSHA Category
- III
- B. 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. C. 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 Intelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3 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: Ability to perform arithmetic operations quickly and accurately. 2 Spatial: 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: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3 Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning 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 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: ________________________.