Clinical Quality Specialist

1. *Commits to the mission, vision, beliefs and consistently demonstrates our core values.

2. *Utilizes quality improvement data to identify areas for improvement and coordinates development and implementation of quality improvement plans for the organization.

3. Acts as a resource to leaders, preceptors, educators and staff for quality improvement processes or staff and patient education.

4. Serves as transformational agent to assure quality improvement efforts are incorporated in all areas of the organization.

5. *Leads and participates in Quality Improvement Teams using literature and best practice evidence to identify opportunities for improvement.

6. *Leads and participates in the development of policies and procedures, order sets, patient education materials, and other resources to support quality improvement projects and goals, as well as regulatory compliance.

7. *Interprets and clarifies definitions of needed data; utilizes data collection techniques and maintains a specified level of accuracy with data collection.

8. *Conducts chart reviews and special audits in accordance with performance improvement and compliance to standards.

9. Analyzes and interprets visual and summarized data findings; evaluates findings in comparison to current and past trends; benchmarks data from other hospitals and standardized information from literature sources.

10. Prepares recommendations for budgetary needs associated with projects.

EDUCATION AND EXPERIENCE:

Graduation from a School of Nursing with current Registered Nurse licensure from the State of Nebraska or approved compact state of residence as defined by the Nebraska Nurse Practice Act. Bachelor's degree required. Minimum of five (5) years progressive clinical nursing experience required.

Risk

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   Support the complaint and grievance process by coordinating investigations, gathering documentation, and tracking follow up activities under the direction of the Director of Quality and Patient Safety.

   
   

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   Coordinate incident reporting workflow activities and facilitate follow up with department leaders under the direction of the Director of Quality and Patient Safety.

   
   

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   Maintains logs and tracking systems of complaints, grievances, and incident, and related follow-up activities

   
   

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   Coordinate and support internal investigation under the direction of the Director of Quality and Patient Safety, including gathering documentation and tracking corrective actions.

   
   

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   Prepare and distribute correspondence related to complaints, grievances, incidents, and risk related matters.

   
   

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   Responsible in preparing complaints, grievance, and incident data for review and presentation to KRMC senior executives.

   
   

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   Works with Director of Quality and Patient Safety in situations of medical malpractice or subpoenas received for any KRMC providers.

   
   

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   Assist with monitoring and documentation activities that support organizational compliance with federal and state regulations, accreditation standards, and internal policies under the direction of the Director of Quality and Patient Safety.

   
   

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   Coordinate and support risk management education and training activities in collaboration with Human Resources, Compliance, and the Director of Quality and Patient Safety.

   
   

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   Participate in Environment of Care (EOC) safety rounds and surveys with EOC committee and assist with documentation and follow-up activities.

   
   

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   Attend meetings, conferences and training courses as deemed necessary for the department.

   
   

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   Review records for completeness, accuracy, and compliance with applicable regulations, standards, and organizational policies, communicate findings to appropriate leadership

   
   

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   Collaborate with leadership to evaluate events and processes for compliance with laws, regulations, accreditation requirements and organizational standards.

   
   

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   Release information to persons or agencies according to regulations, including subpoena requests, with the authorization of leadership.

   
   

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   Demonstrate strong attention to detail and the ability to prioritize, organize and manage multiple responsibilities effectively.

   
   

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   Maintains effective communication and collaborative working relationships with the Director of Quality and Patient Safety, medical staff, leadership, and KRMC employees.