Johnson Service Group (JSG) is seeking a Quality Standards Coordinator (LVN) in Orange County. This is an onsite position.
Qualifications
- Licensed Vocational Nurse (LVN)
- Current Licensure in the State of CA
- Hold a minimum of a High School Diploma or GED.
- Have prior work experience in healthcare.
- Possess excellent written and oral communication skills.
- Possess knowledge of standards, survey methodology and related tools and resources for regulatory and accreditation requirement
Maintain knowledge of:
Clinical best practices
- Accreditation and regulatory standards
- Quality improvement processes
- Quality Standards Manual
- Governing Body (GB) and Medical Executive Committee (MEC) Bylaws
- Center Medical Staff Rules & Regulations
- Center Policies and procedures
- Infection Control guidelines
- Nationally recognized patient safety goals (NPSGs) for ASCs
- Environmental safety regulations and guidelines
- Center Environment of Care (EOC) Manual
- Center Medical Staff Services and Credentialing guidelines
- Center Medical Staff Services and Credentialing Manual
- Center and regional education, orientation, and training programs
- ASC center leadership responsibilities
- Center Homepages: Clinical Resources, Quality Standards, Environment of Care, Credentialing
Lead, facilitate, and advise the Center Quality Council and internal performance improvement teams:Set the agenda and maintain meeting minutes
- Ensure reporting of all mandatory and center specific monthly and quarterly reports for trends/areas for improvement to the Quality Council and Medical Executive Committee/Governing Body a minimum of quarterly:
- Medical Record Audit reports; Monthly or quarterly data collection from ongoing systematic chart review to assess quality of documentation.
- Infection Control reports
- Hospital Transfer/Complication reports
- Patient Safety; measurement of key measures of patient safety and hazard analysis/process redesign (adverse events, root cause analysis).
- Life safety (environment of care); Provide for a detailed assessment and evaluation of the Environment of Care (EOC) and the associated conditions, staff education and readiness and the various processes. Framework for the EOC includes the management processes and systems that affect safety, security, hazardous materials, emergency preparedness, life safety, medical equipment, and utilities management.
- Risk Management (incident reporting)
- Adverse Drug Reaction reports
- Cancellation logs
- Service Satisfaction reports (patients, staff and physicians)
- Center specific quality indicator reports as appropriate
- PI reports; Collection, analysis and summary of performance improvement data.
Provides strategic oversight of proactive and reactive patient safety activities:
Root cause analysis.
- Clinical practice guidelines
- Sentinel Event Alerts
- Identification and data collection of center specific quality indicators based on high risk, problem prone procedures as appropriate.
- Review and revision of the PI Plan on an annual basis and preparation of the annual report of the PI program to the Medical Executive Committee/Governing Body.
- Documentation of all Performance Improvement activities and maintenance of records for a minimum of three years.
Provides strategic oversight of proactive and reactive patient safety activities (continued):
- Coordination of the center policies/procedures and processes to be in compliance with the current standards of applicable regulatory and accrediting agencies, and mandatory Corporate policies.
- Working with the Administrator/designee to ensure currency of all physician files, medical staff appointments and/or privileges and compliance with credentialing policies and procedures. Coordinating as appropriate the peer review process and aggregate individual peer review data for presentation and review by the Medical Executive Committee and Governing Body at reappointment.
- Working with the Administrator/designee to ensure currency and completeness of all human resource and education files for center employees and contract personnel.
Maintain Center Survey readinessAssess center compliance with accreditation standards and regulations in collaboration with leadership and staff.
- Identify areas of vulnerability and direct the development of strategies to enhance compliance.
- Provide the overall direction necessary to ensure that clinical services provided are evidence-based, in accordance with standards established through state and federal regulations and applicable accreditation standards, including the National Patient Safety Goals.
Communicate Effectively Throughout All Levels of the Organization
Proactively educate and train the leadership and staff regarding regulatory issues, new statutes/guidelines, and safety/quality/performance improvement activities and their respective responsibilities in carrying out the performance improvement program.
- Maintain effective communication on current center activities related to Safety/Quality/PI and Accreditation and seek consultation as needed for support from the Regional Quality Coordinator or assigned Group Director.
** Johnson Service Group (JSG) is an Equal Opportunity Employer. JSG provides equal employment opportunities to all applicants and employees without regard to race, color, religion, sex, age, sexual orientation, gender identity, national origin, disability, marital status, protected veteran status, or any other characteristic protected by law.