This position partners with physicians, leadership, and staff to evaluate the quality of clinical care and identify improvement opportunities. This position assists in the resolution of quality issues by facilitating root cause analysis and action planning to prevent reoccurrence of identified system issues. This position assists in the monitoring, measurement and analysis of quality indicators and other data to identify clinical risk management issues and initiates/facilitates changes to reduce institutional risk.
Provides QI 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.
Facilitates and assists in implementing evidence-based practice strategies to improve outcomes. Assists in the achievement of quality improvement objectives and takes necessary modifications for attainment of goals.
Analyze, report, and review MIPS data and recommended improvement activities
Directs an effective organization Infection Prevention Program under the leadership of the Infection Prevention Medical Director and the Infection Prevention Committee.
Assures surveillance activities are accurate & timely
Assures reports/data are disseminated internally and externally as requested or required
Monitors data/outcomes and alerts appropriate physicians, administration or staff when concerns are identified
Works with Medical Director to assure thorough investigations are completed when outbreaks are identified
Assures an Infection Prevention Risk Assessment is completed annually, and initiatives/goals are set based on the assessment
Assures participation in UPHDM improvement activities focused on the reduction of infections
Coordinates medical provider and nursing staff peer review processes
Coordinates root cause analysis and action plan tracking for sentinel events and major quality concerns as needed
Acts as the local administrator for the occurrence reporting system; troubleshooting, acting as the liaison with corporate system administrators, granting local security and report writing
Demonstrates the UnityPoint Health Values and Standards of Behaviors as well as adheres to policies and procedures and safety guidelines.
Demonstrates ability to meet business needs of department with regular, reliable attendance.
Employee maintains current licenses and/or certifications required for the position.
Practices and reflects knowledge of HIPAA, TJC, DNV, HFAP, OSHA and other federal/state regulatory agencies guiding healthcare.
Completes all annual education and competency requirements within the calendar year.
• Bachelor’s Degree in Nursing
• 2 years’ work experience in healthcare
• Valid driver’s license when driving any vehicle for work-related reasons.
• Certification in Infection Control (CIC) or obtain with 2 years
• Understanding of clinical process improvement methods and tools (i.e., root cause analysis)
• Group facilitation knowledge/skill
• Excellent oral and written communication skills
• Work may require travel using own vehicle.
• Use of usual and customary equipment used to perform essential functions of the position.
• Master’s Degree
• Background in Quality Improvement, Adaptive Design, Lean, or Six Stigma, or Infection Prevention
• Certification in Healthcare Quality or Healthcare Risk Management