Description
Standard Qualifications: St. David's Georgetown Hospital is part of St. David's HealthCare, one of the largest health systems in Texas, which was recognized with a Malcolm Baldrige National Quality Award in 2014. St. David's Georgetown Hospital offers a range of services, including a 24-hour emergency department with a level IV trauma center; Certified Primary Stroke Center; Certified Chest Pain Center; inpatient and outpatient surgery; advanced pulmonary intervention; critical care capabilities; acute inpatient and outpatient rehabilitation; and maternity and newborn services with mother-baby couplet care close to home for Georgetown families. In conjunction with its parent campus, St. David's Medical Center, Healthgrades awarded St. David's Georgetown Hospital the 2016 America's 100 Best Hospitals Award , 2016 Patient Safety Excellence Award and the 2016 Outstanding Patient Experience Award -a unique trio of awards that only three hospitals in the nation were able to achieve-as well as the 2016 Distinguished Hospital Award for Clinical Excellence. Additionally, St. David's Georgetown Hospital was named to the list of 100 Top Hospitals by Truven Health Analytics for four years in conjunction with its parent campus, and the facility earned a national distinction for patient safety from The Leapfrog Group from 2012 to 2016. POSITION SUMMARY The Quality Coordinator implements and oversees the facility quality and performance improvement (PI) programs, including outcomes analysis. The Coordinator promotes performance improvement, staff education, and development. ESSENTIAL JOB RESPONSIBILITIES - Implements and oversees quality activities throughout the facility. o Collaborates with the Director to develops, revise, and implement quality and PI plan. o Serves as a quality resource to all departments, staff, etc. o Maintains and coordinates quality and PI report cards, dashboard, and other reporting mechanisms. o Serves as member of selected facility and departmental PI committees, teams. Serves as Quality Facilitator/Leader of root cause analysis teams, (RCAs), FMEAs, as requested by Quality Director o Ensures compliance of corporate, regulatory, and accreditation requirements for quality, performance improvement, and patient safety. o Serves as representative to selected Partnership and other quality committees, initiatives, etc. o Coordinates quality activities with Quality and other staff. o Collaborates with Director in implementing patient safety, national, corporate and other quality or patient safety initiatives. Leads and facilitates designated initiatives. - Responsible for data analysis, collection and outcomes measures. o Analyzes and reports data from clinical outcomes systems such as CHOIS, TMF, Core Measures/COMET, THCIC, Q-Net, etc. as required or requested. o Recommends action plans based on clinical and other data to the Director, Medical Director, Medical Staff, Quality Management Committee, Administration, etc. o Analyzes and reports satisfaction data and suggests action plans to Administration, etc. o Manages Core Measure reporting and other outcomes measures as determined by the Medical Staff, Administration, etc. o Collects and reports physician quality data for reappointment. Ensures collection, maintenance, and reporting of data for profiles (medical staff and allied health professionals) in a timely manner to ensure quality data and/or recommendations for physician credentialing and appointment/reappointment activities. Provides profiles to Medical Staff Department for credentialing and quality file purposes, and to the respective practitioner. o Maintains quality and PI software and reporting systems to meet internal and external reporting requirements and surveys. Assists with selection and installation of software applications. o Participates in the review of concurrent measures for public reporting purposes. - Completes administrative and other duties as needed. o Provides input in departmental goals, objectives, budget. o Maintains confidentiality. o Performs other duties as assigned. o Complies with all hospital policies and procedures, safety requirements, and emergency preparedness requirements. - Coordinates the medical staff performance improvement review process. o Identifies cases for potential review based on clinical indicators. o Coordinates review of cases by medical staff. o Plans and facilitates regular Physician Performance Improvement Committee meetings and records minutes appropriately. o Conducts OPPE and FPPE according to established procedures. - Employee's conduct must reflect the Company's values and commitment to the Code of Conduct ethics and compliance program. - Adheres and upholds all service behaviors as listed in the I CARE value commitment and other departmental initiatives.
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