At Central Maine Healthcare our team members are committed to providing exceptional care and experiences for our community and for each other every day.
Position Summary: The Clinical Quality Review Coordinator is responsible for the collecting, organizing, analyzing and presenting data about the hospital's performance in order to provide statistically valid information that will assist staff to improve overall Quality. The Clinical Quality Review Coordinator is also responsible for clinical identification, risk evaluation and coordination of corrective action implementation related to risk issues. Reports real and potential risk situations to manager, administration, and committees as appropriate; provides intervention and education related to risk management issues to promote safe work practices and quality care and service; in an environment that is beneficial to the safety, health and well being of all patients, visitors and staff. Facilitates performance improvement activities and CQI activities throughout the facility. Acts as a resource person to administrative team, department managers and medical staff. Assists with all regulatory body surveys; JCAHO (if applicable), State Licensing Review, HCFA (CMS) Validation Surveys, etc.
Duties and Responsibilities:
Demonstrates Competency in the Following Areas:
1. Collects and aggregates all events reported within the hospital.
2. Issuing monthly reports of events to all department heads and members of the executive management team.
3. Prepares chart abstractions for clinical events to be reviewed by the Medical Care Review Committee.
4. Analyzes, trends, and supplies data as requested by the medical staff or other hospital departments for the purpose of quality improvement or practice pattern analysis.
5. Consults other departments as appropriate to collaborate in patient care, risk management, and performance improvement activities.
6. Gather data, submit and coordinate reports related to QI and/or RM for the following: Core Measures, CMHC goals, Board of Directors, CMS, Anthem Contract, State, and others as directed by Administration.
7. Assists with compliance with JCAHO (if applicable), State and other regulatory agency standards.
8. Participates in regional PHO activities.
9. Maintains association in national &/or local quality improvement/risk management professional organizations.
10. Demonstrates management and communication skills necessary for the development, implementation, coordination and documentation of Quality Improvement activities. Reviews and updates the hospital Quality Improvement (QI)/Risk Management (RM) Plan, Event Reporting Policy and other policies as needed for approval by the appropriate committees.
11. Prepares agendas, provides analyzed or trended data and attends Clinical Practice Committee (CPC) meetings.
12. Coordinates the Quality/Process Improvement program
13. Acts as a resource to department managers in developing annual program initiatives, Scope of Service Designs, etc.
14. Reviews event report worksheets for the purpose of identification of real or potential risk or quality issues, and suggests action to the department manager as appropriate.
15. Reviews sentinel events and near miss occurrences and facilitate the root cause analysis.
16. Interacts professionally with patient/family to increase patient/family satisfaction and/or diffuse potential litigious occurrences related to patient/family perception as directed by Manager or Administration.
17. Advises staff, providers and/or committees regarding real or potential liability situations as directed by Manager or Administration.
18. Coordinates risk management, performance improvement and patient relations information as needed for administrative activities, credentialing and hospital insurers
19. Assists with reviews, evaluates and recommends action on risk related matters pertaining to patients, visitors, employees, physical plant and personal property.
20. Complies with Bridgton Hospital's policies, procedures and maintains confidentiality and good public relations.
21. Follows the designated chain of command when controversy arises regarding any issues of concern.
Professional Requirements:
22. Adheres to dress code, appearance is neat and clean.
23. Completes annual education requirements.
24. Maintains regulatory requirements including all state, federal and JCAHO (as applicable) regulations.
25. Reports to work on time and as scheduled.
26. Wears identification while on duty.
27. Attends annual review.
28. Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
29. Represents the organization in a positive and professional manner.
30. Actively participates in performance improvement and continuous quality improvement (CQI) activities.
31. Attends committee meetings as appropriate.
32. Complies with all organizational policies regarding ethical business practices.
33. Communicates the mission, ethics and goals of the facility
Organizational Requirements:
34. Customer Service: Interacts with all individuals in a consistent manner, providing attention, support, and assistance to foster an environment of exceptional personal service.
a. Maintains a pleasant and helpful demeanor, and presents a professional appearance toward all internal and external customers at all times.
b. Consistently initiates interaction to provide assistance to individuals who may not be direct customers of the employee (i.e. asks patients who appear to be lost if they need assistance in finding their way).
c. Takes appropriate action to recover from a service difficulty, ensuring that the necessary action is taken to affect a resolution to the customer’s problem.
d. Conducts all work activities with respect for coworkers, including the maintenance of a pleasant and professional environment, fostering calmness during stressful situations.
e. Interacts with supervisory personnel in a professional, supportive and courteous manner, venting emotions appropriate to time and place.
f. Demonstrates a commitment to service by consistent attendance and punctuality, scheduling absences according to departmental requirements, and incurring unplanned absences only when unavoidable circumstances exist.
35. Confidentiality: Maintains confidentiality of information at all times.
a. Consistently maintains confidentiality of all information gained during the course of employment, respecting the privacy of others.
b. Understands and maintains the confidentiality of information communicated directly from the supervisor, including discussions of a counseling nature.
c. Follows policies and procedures related to medico legal matters, including confidentiality, amendments of medical records, patient rights, medical records as legal evidence and informed consent
d. Copies records according to policy, assuring the appropriateness of the individual requesting information from the record prior to copying, faxing, or phoning any portion of the record.
36. Safety: Demonstrates an understanding of fire and electrical safety, infection control, body mechanics, and related areas, as appropriate to position.
a. Attends mandatory in-services on fire safety, electrical safety, infection control, and body mechanics. Successfully completes competency-based training in each area.
b. Follows all employee health procedures, event reporting, and infection control requirements at all times, as appropriate to the position.
c. Uses proper body mechanics at all times as required by the physical demands of the position.
d. Maintains a safe work environment and performs duties of the position in a manner consistent with ensuring the safety of self and others.
e. Identifies safety needs in areas outside own work environment, recommending corrective action as appropriate.
f. Past task exposure determination has placed this job position and hepatitis vaccine program as a Category II.
37. Expense Control: Performs job duties in a manner that maximizes expense control.
a. Uses supplies, equipment, and utilities in an expeditious manner
b. Consistently recommends methods to control costs while maintaining a high degree of customer service.
c. Performs job tasks efficiently and effectively resulting in no unplanned overtime.
Requirements:
• Must have graduated from an accredited school of nursing and possess a valid and current RN license by the Maine State Board of Nursing.
• Must have five years of acute care clinical experience.
• Must have experience with various personal and mainframe computer programs including databases, spreadsheets, graphics and word processing.
• Graduate of a 2-3 year program in business, math, statistics, and computer sciences helpful.
• Have experience in Quality/Risk Management.
Language Skills:
• Ability to effectively communicate in English, both verbally and in writing.
• Excellent communication and presentation skills.
• Additional languages preferred.
Skills:
• Excellent computer knowledge; experience with Excel, Access, Windows, word processing, spreadsheets, graphing, charts, various software, etc.
Physical Demands:
• For physical demands of position, including vision, hearing, repetitive motion and environment, see following description.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position without compromising client care.
If you are passionate about making a difference and are looking for your next great career opportunity, we look forward to reviewing your application!