Your job is more than a job.

This job description is intended to describe the general nature and level of work performed by employees assigned to this department. This is not an exhaustive list of all duties and responsibilities, and LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.

GENERAL DUTIES

Overall:
- Coordinates, integrates and facilitates hospital wide Quality Improvement, Accreditation, Risk Management, Infection Control and Clinical Outcomes Database programs.
- Reviews and revises plans, objectives scope, organization of the Quality Improvement, Risk Management and Infection Control programs.
- Serves as consultant to Medical Departments, Medical Staff Committees and Hospital Departments in the development of their respective Quality Improvement programs.
- Serves as an active participatory member on hospital committees and Medical Staff Committees.
- Supervises staff responsible for Quality Improvement, Infection Control, Clinical Outcomes Programs, etc.
- Selects and ensures adequate training of department staff.
- Develops standards of performance, evaluates performance on an annual and ongoing basis.
- Develops, recommends, implements the departmental operating budget. Ensures the department operates within the budget.Risk Management:
- Reduces liability exposure of hospital through the Risk Management program.
- Conducts preliminary investigations of unanticipated or adverse Patient Safety events or other related events and report findings.
- Facilitates root cause analyses (RCAs) utilizing organizational tools and processes, participates and assists in the coordination of RCA) teams at the direction of the Medical Director.
- Recommends, facilitates and implements change within the organization to improve patient safety, based on identified risks.
- Designs and implements educational presentations that facilitate understanding and implementation of patient safety standardsAccreditation:
- Facilitates compliance with the Centers for Medicare and Medicaid Services (CMS), The Joint Commission standards and regulations of all accrediting, licensing and reviewing bodies.
- Keeps abreast of regulatory agency standards and assures that the hospital is in compliance with current Centers for Disease Control, Occupational Safety and Health Administration, state regulations concerning Infection Control and environmental safety.
- Assures readiness to demonstrate compliance with relevant regulatory standards and applicable laws.
- Oversees tracer related activities to ensure ongoing compliance.Patient Safety and Quality:
- Assists in the development of an integrated hospital database for quality improvement.
- Manages the cross-campus patient safety program including ensuring compliance with state and local regulations, national patient safety goals, the Joint Commission Standards, OSHA and other regulatory requirements.
- Recommends indicators and criteria, facilitates data gathering and analysis, identifies patterns and trends, facilitates identification, documentation and resolution of improvement opportunities.Infection Control:
- Provides consultation and recommendations for infection control practices, policies and procedures.
- Assists the Infection Control Committee in evaluation and revision of hospital infection control practices and aseptic techniques.
- Ensures the maintenance and reporting of surveillance activities as defined by the Infection Control Committee.
- Ensures the reporting of required communicable diseases to local public health departments in accordance with their specifications.
- Oversees, investigates, identifies outbreaks and cluster infections and presence/detection of unusual pathogens.

EXPERIENCE QUALIFICATIONS

Minimum of 7 years of experience in Performance Improvement, Infection Control, Quality Management, Patient Safety etc. and 2 years under Management/Supervisory capacities in healthcare settings required

EDUCATION QUALIFICATIONS

Required: Bachelor's Degree in an Allied Health filed or equivalentPreferred: Master's Degree in an Allied Health filed or equivalent

LICENSES AND CERTIFICATIONS

Certification Name: Registered Nursing LicenseRequiredIssuer: Louisiana State Board of NursingLicensure Speciality: Licensure

SKILLS AND ABILITIES

Must exhibit excellent human relations and oral/written communication skills.Answer telephones and take messages.Input data into computer programs.Maintain filing systems and logs.Proofread documents.Research information/data and document findings.Prepare summaries for presentations.Must be adept at utilizing personal computer, fax machine and photocopier.

REPORTING RELATIONSHIPS

Does this position formally supervise employees? Yes

WORK SHIFT:

Days (United States of America)

LCMC Health is a community. 

Our people make health happen. While our NOLA roots run deep, our branches are the vessels that carry our mission of bringing the best possible care to every person and parish in Louisiana and beyond and put a little more heart and soul into healthcare along the way. Celebrating authenticity, originality, equity, inclusion and a little “come on in” attitude is the foundation of LCMC Health’s culture of everyday extraordinary

About University Medical Center

University Medical Center, a world class academic medical center in LCMC Health’s incredible community of care, is the largest medical training center for healthcare professionals in Louisiana and has long served as the region’s safety net hospital for poor and underserved communities for 300+. Learn more about University Medical Center’s legacy and our vision of becoming the epicenter of medical care, education, and research.

Your extras

Deliver healthcare with heart. Give people a reason to smile. Put a little love in your work. Be honest and real, but with compassion.  Bring some lagniappe into everything you do. Forget one-size-fits-all, think one-of-a-kind care. See opportunities, not problems – it’s all about perspective. Cheerlead ideas, differences, and each other. Love what makes you, you - because we do

You are welcome here. 

LCMC Health is an equal opportunity employer. All qualified applicants receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability status, protected veteran status, or any other characteristic protected by law.

The above job summary is intended to describe the general nature and level of the work being performed by people assigned to this work. This is not an exhaustive list of all duties and responsibilities.  LCMC Health reserves the right to amend and change responsibilities to meet organizational needs as necessary.

 

Simple things make the difference. 

1.    To get started, take your time to fully and accurately complete the application for employment. Incomplete applications get bogged down and are often eliminated due to missing information. 

2.    To ensure quality care and service, we may use information on your application to verify your previous employment and background.  

3.    To keep our career applications up-to-date, applications are inactive after 6 months and, therefore, require a new application for employment to be completed. 

4.    To expedite the hiring process, proof of citizenship or immigration status will be required to verify your lawful right to work in the United States.