QUALITY COORDINATOR (33744)

Essential Functions

Responsible for duties, which include but are not limited to Quality and Performance Improvement, Infection and Hazard Control, Employee Safety, Emergency Preparedness, Workplace Violence, and Interim Life Safety programs. Assists with organizational quality outcomes in accordance with Federal and State (Georgia and Alabama) regulations, NHPCO standards, Joint Commission standards, and OSHA standards.

Challenges in Position

Frequent multi-tasking. Frequent interruptions. Coordination of several jobs at one time. Prioritization of competing needs. Complexity of rules and regulations require critical thinking and interpretation.

Qualification Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily with professionalism and mutual respect for all. The requirements in this job description are representative of knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and Experience

• Associates degree or equivalent from two-year College or technical school in nursing required.
• BSN or MSN preferred
• Knowledge and experience with State and Federal regulatory compliance, The Joint Commission accreditation, HIPAA, and quality outcome measurement and analysis preferred
• Computer literate, proficient in Word, Excel, and PowerPoint required
• Must have strong written and verbal communication skills, critical thinking, and problem solving skills

Certificates, Licenses, Registrations, Vaccines

• Active RN licensure in Georgia and Alabama required (or multistate compact license)
• Certification in Hospice & Palliative Care preferred (must obtain within one year of position placement)
• CPR Certification required upon hire or must obtain within approved time period
• Valid drivers’ license and good driving record required
• Valid automobile insurance per policy required
• Reliable personal transportation required
• Influenza vaccine during influenza season required

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form. Ability to define problems, collect data, establish facts, and draw valid conclusions.

Language Skills

Ability to read, analyze, and interpret common scientific and technical journals, financial reports, and legal documents. Ability to respond to common inquiries or complaints from patients and/or family members, regulatory agencies, or members of the business community. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of managers, clients, customers, and the general public. Ability to respond effectively and appropriately to the most sensitive inquiries or complaints.

Position Requirements (not all-inclusive)

• Maintain a continuous awareness of regulations and standards specific to hospice care and communicates requirements to leadership.
• Ability to prepare and analyze reports
• Complete assigned chart audits, creating and submitting associated reports as needed. Collaborates with managers to design and implement procedures to correct problem areas.
• Responsible for the QAPI program, to include chart audits, maintenance of audits, creation and submission of reports, and collection of data.
  • Reports results to supervisors and employees at least quarterly, and more often as requested or needed to address a performance issue.
  • Collaborates with managers to design and implement procedures to correct problem areas.
  • Coordinates and/or conducts ongoing performance improvement projects based on needs identified through data monitoring and analysis and satisfaction and survey results.
• Responsible for submitting Hospice Outcomes and Patient Evaluation records to CMS within established timeframes.
• Responsible for submitting the CAHPS file to the contracted Vendor within timeframes established by the vendor and CMS.
• Track incident reports, maintains records, and recommends staff education topics regarding variance report trends.
• Chair the Health & Safety committee and provides guidance to assigned staff. Responsible for effectiveness of Health & Safety committee/program.
• Serve as the Emergency Preparedness Coordinator. Maintains knowledge of emergency preparedness requirements. Responsible for coordinating required drills and meetings in Georgia and Alabama offices.
• Serve as Infection Control Coordinator; assists in maintaining related policies and procedures based on best practice and current research, assists in routine infection control data surveillance, and assists staff orientation and education related to infection control.
• Responsible for the Workplace Violence Prevention Program to include updating workplace violence plan, awareness of OSHA standards in coordination with HR, conducts annual hazard vulnerability assessment, distributes annual workplace security risk survey, and presents assigned topics in new employee orientation education.
• Responsible for the Hazard Communication Program to include awareness of and agency compliance with OSHA standards in coordination with HR, annual update of the Hazard communication plan and policy as needed, and presents assigned topics in new employee education.
• Assist in creating and revising policies and procedures related to this job description and as assigned.
• Assist in annual education of staff related to topics in this job description and as assigned.
• Initiate and lead root-cause analysis teams related to sentinel events.
• Responsible for maintaining the Exposure Control Plan.
• Responsible for maintaining the Elopement Prevention and Management Program.
• Participate as needed in mentoring to improve staff competency for activities related to quality.
• Participate in The Joint Commission accreditation processes of Columbus Hospice and surveys by regulatory and other accrediting agencies. Serves as backup to Compliance officer in surveys.
• Provide backup support and coverage for the Compliance Officer.
• Coordinate with the Compliance Officer to present required quality data to the Board of Directors. Participates in Board/Staff Compliance meetings.
• Demonstrate commitment to the mission and service excellence process by adhering to all facets of the Columbus Hospice standards, policies and procedures, Federal and State licensure requirements, NHPCO Standards of Care, and the Joint Commission standards.
• Attend mandatory in-service education and staff meetings.
• Participate in staff development as required, to include 15 hours of CEUs per evaluation year as per Columbus Hospice policy.
• Take all reasonable precautions to maintain privacy and non-disclosure of any confidential information about patients, other staff members, and the general operations of Columbus Hospice, Inc.
• Represent the company in a positive and professional manner at all times with others, e.g., co-workers, management, vendors, and customers.
• Complete all job responsibilities in a thorough and complete manner, utilizing good judgment in all aspects of the job, including attendance requirements and prompt arrival at work.
• When unsure of a directed task or any part of job responsibilities, proactively seeks the assistance of immediate supervisor.
• Assist with special projects, as requested.
• All other job duties as may be assigned.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; sit; use hands to finger, handle, or feel; and reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, crouch. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception, and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is rarely exposed to outside weather conditions. The noise level in the work environment is usually low.

This job description is not intended to be a complete statement of job content, rather to act as a guide to the essential functions performed. Management retains the discretion to add or to change the duties of the position at any time.