Quality/ Sepsis Coordinator

POSITION PURPOSE

Under general supervision of the Manager, the Quality Coordinator is responsible for the review, abstraction, and analysis of Quality Core Measures and performance measures for the Center of Medicare Services (CMS), Accrediting Organizations, and the Department of State Health Services (DSHS). This is a key position in assuring that the organization stays compliant with mandatory reporting requirements and performance improvement efforts. This position coordinates Specialist coordinates and organizes Quality, Infection Control, & Risk Management functions and routines. Performs a variety of word processing, filing, and general office duties. Serves as a specialist in data support, data analysis and budgeting for those areas. Maintains systems established within the department. Demonstrates understanding of the philosophy, objectives, and adheres to policies and procedures of the department and organization.

ESSENTIAL JOB FUNCTIONS

Every effort has been made to make this job description as complete as possible. However, it in no way states or implies that these are the only duties the incumbent will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or is a logical assignment to the position.

• Maintains hospital Policy & Procedures database; coordinates hospital Policy & Procedures meetings.
• Communicates with hospital leaders to ensure policies and procedures are reviewed and revised within standard timeframes to ensure compliance with state rules, accrediting organizations, CMS and other agencies as applicable.
• Assists with the development and implementation of new policies and procedures.
• Works closely with Nurse Informaticist, department leaders, Medical Staff Services and others to ensure information is communicated appropriately about new or revised policies.
• Takes meeting minutes at various meetings and sends for review and approval.
• Assists with Core Measures, Leapfrog and other required data abstraction and submission.
• Abstracts sepsis records and other moderate to highly complex clinical data using established guidelines. Maintains abstracting volumes to meet internal/external reporting deadlines to required regulatory agencies.
• Performs clinical review of a medical record and summarize the findings; accurately enter information into database as specified.
• Conducts analysis of data in cooperation with the medical staff to assist in identification of improvement activities. Provides documented reports of findings from data collection as requested.
• Understands current issues, practices and trends in healthcare. Maintain knowledge of CMS, Accrediting Organizations, Core Measure, PI Methodology, and State of Texas reporting requirements.
• Determines and negotiates the validity of the abstracted data and questions controversial information prior to data entry. Solves problems with regard to unique record or process issues and assists in implementation of PI processes.
• Assist with the survey accreditation process by maintaining appropriate documents, Environmental & Rounds: updates environmental rounds forms, input data into computer, send copy of reports to appropriate personnel on a weekly basis, and oversees survey readiness process.
• Audits Restraint Usage and reports, ensuring compliance with CMS requirements. Ensures compliance with time sensitive documents and confidential data support functions.
• Reportable diseases - Completes appropriate reporting forms for diseases to be reported to DSHS and faxes forms and lab slips to appropriate service within DSHS.
• Completes and sends out post-op letters to surgeons monthly for surveillance of SSI.
• Provides data support involving the prevention and control of hospital associated infections through various data collection; maintains database and spreadsheet files.
• Worker’s Compensation / Employee Injuries: maintains records of cost reporting and assists Employee Health Nurse with processing paperwork and schedules any follow-up appointments for ER or clinic.
• Maintains databases for Infection Control / Employee Health: Scans in Employee Health records and converts all employee health immunization records to electronic format.
• Sends out monthly reminders to department leaders to report required data on Hand Hygiene and PPE Compliance. Tracks responses and inputs data into charts. Distributes results of data and summary.
• Assists Employee Health Nurse with Fit Testing new employees and annually.
• Abides by the HMH Legal Compliance Code of Conduct.
• Maintains patient confidentiality and appropriate handling of PHI.
• Maintains a safe work environment and reports safety concerns appropriately.
• Performs all other related duties as assigned.

LATITUDE, CONTACTS/INTERACTIONS

All positions of Huntsville Memorial Hospital are part of an interdisciplinary team, and as such, participate in the care and service delivery process through effective interaction with other team members. Primarily interacts with hospital staff, medical staff, patients, and visitors.

Requirements

Education: Graduate of a vocational or professional nursing program required.

Experience: Two years of experience in healthcare with clinical chart review, health information management and/or data abstraction preferred.

Licensure/Certification: None required. Current licensure as a Registered or Vocational Nurse in the State of Texas, preferred.

Required Skills: Excellent oral and written communication, organizational and data management skills

Benefits

• Health Care Plan (Medical, Dental & Vision)
• Retirement Plan (401k, IRA)
• Life Insurance (Basic, Voluntary & AD&D)
• Paid Time Off
• Short Term & Long Term Disability
• Training & Development
• Wellness Resources