Quality Assurance Performance Improvement Coordinator at HOSPICE OF EL PASO, INC – El Paso, Texas

PURPOSE OF POSITION

The Registered Nurse (RN), under the supervision of the Director of Compliance and with clinical oversight and collaboration from the Director of Nursing (DON), coordinates and oversees quality improvement, clinical education, infection control, and employee health for the agency’s hospice and palliative care services. The RN plans, gathers, monitors, analyzes, and reports data related to performance improvement, patient safety, and regulatory requirements, and serves as the Infection Control Practitioner and Employee Health Nurse.

The RN provides clinical education, competency development, and evaluation for nursing and patient care staff, utilizing evidence-based practice to ensure patient care plans are appropriate, individualized, implemented, and regularly evaluated. The RN also participates as a member of the QAPI team to assist in the implementation and evaluation of the organization’s Quality Assessment and Performance Improvement program and related initiatives in accordance with regulatory standards, physician orders, and agency policies and procedures.

DUTIES AND RESPONSIBILITIES

Listed below is an outline of the major duties and responsibilities that will be required. Administrative authority, responsibility, and accountability necessary to perform the assigned duties under the supervision of the Director of Compliance and QAPI are delegated to this position.

DUTIES

1. Assists in developing systems that promote the delivery of high-quality interdisciplinary team services, including home care, inpatient and contracted services via the development, implementation, analysis, and ongoing revision/evaluation of the Agency Performance Improvement Plan and related Safety Plans.
2. Maintains complaint and occurrence logs and files. Addresses and works toward resolution of all complaints within seven days.
3. Collects, tabulates, and analyzes QAPI data. May request the assistance of other Hospice personnel to assist with this task with the approval of their supervisor.
4. Reports QAPI findings and recommendations to the leadership team and ensures leadership accountability for performance improvement activities.
5. Audits and supports implementation and compliance with HOPE requirements and other regulatory changes.
6. In collaboration with the Director of Compliance & QAPI, ensures compliance in all areas to the accrediting agency, CMS, state and federal standards and requirements.
7. Ensures the QAPI program meets CMS Conditions of Participation (CoPs) requirements, including data-driven, ongoing, and agency-wide performance improvement activities.
8. Reviews clinical areas including symptom management and continuity of nursing care seeking opportunities for continuous improvement.
9. Maintains complete records concerning all IDT activities.
10. Develops and presents performance improvement projects to the QAPI Committee, medical staff, and governing body.
11. Compiles results of all satisfaction surveys presenting results to the staff and to the QAPI Committee for quarterly review and benchmarks against any available national data.
12. Prepares an annual report to summarize QAPI and Infection Control activities.
13. Prepares a new QAPI Plan each year.
14. Executes duties related to risk management which include, but are not be limited to:
15. Promotes blood borne pathogen standards compliance.
16. Monitors, records, and tracks infection control trends. Prepares monthly report for county health department.
17. Benchmarks adverse drug reactions with national data when pertinent.
18. Maintains employee health and training file.
19. Tracks patient-related occurrence reports and monitors for trends.
20. Conducts root cause analyses for adverse events and implements corrective action plans with ongoing monitoring for effectiveness.
21. Serves as Chairperson for the QAPI Committee.
22. In conjunction with the Medical Director and DON and consistent with CDC recommendations, develops and implements a comprehensive infection control and prevention plan.
23. Implements a comprehensive employee health program to include but not be limited to TB testing, immunization evaluation, exposure control, and initiative to foster ongoing employee health.

RESPONSIBILITIES

1. General
2. Shall know and conform to the Texas Nursing Practice Act as delineated in Title 3, Subtitle E, Chapter 301 of the Texas Occupations Code, the Board of Nurse Examiner’s standards, rules and regulations as delineated in Title 22, Part 11 of the Texas Administrative Code, as well as all federal, state, or local laws, rules or regulations affecting the nurse’s current are of nursing practice.
3. Maintains Licensure as required by Title 3, Subtitle E, Chapter 301 of the Texas Occupations Code and Title 22, Part 11, of the Texas Administrative Code.
4. Notifies Hospice immediately of any pending action against the license or pending suspension or any suspension or action taken against the license.
5. Provides information gathered from studies to assist in evaluating the clinical competence of staff, volunteers, and contracted services when requested.
6. Keeps appropriate personnel informed about trends, issues, problems, and potential risks that might have an impact on the quality of care.
7. Executes the infection prevention program and uses the primary Medical Director as the medical resource for infection related clinical issues.
8. Executes the employee health program to foster employee health throughout the Agency.
9. Functions independently, has personal integrity, flexibility, and the ability to work effectively with other personnel under varying circumstances.
10. Participates in staff in servicing.
11. Has knowledgeable of and follows Hospice policies and procedures.
12. Maintains a professional appearance.
13. Displays a consistent positive attitude.
14. Demonstrates Values of Hospice.
15. Adheres to Hospice El Paso Mission and Value Statement.
16. Maintains a high degree of confidentiality.
17. Performs other duties as assigned.

Communication

1. Develops and maintains a cooperative manner with patients/families and professionals and support staff working in hospitals, foster homes, nursing homes, and related facilities.
2. Listens and responds to the patient/family needs in a sensitive and timely manner keeping all parties apprised of developments.
3. Establishes and maintains effective communication with agents representing the community as well as all departments of Hospice.
4. Communicates effectively, both verbally and in writing, with all levels of Hospice staff.
5. Complies with HIPAA standards by abiding with minimum Protected Health Information necessary to perform job description responsibilities.

Professional Development

1. Attend and participate in team meetings, IDT, and patient care conferences.
2. Attends and participates in in-services, education classes and on-the-job training programs as required with annual education in infection prevention practices.
3. Attends conferences and workshops as approved.
4. Participates in orientation of employees, volunteers, and students as assigned.
5. Attends ethics and compliance training and maintains compliance with CCP.

QUALIFICATIONS

1. Education and Experience
2. Valid professional registered nurse license in the State of Texas.
3. Minimum of two years of experience practicing as a registered nurse.
4. At least one year of Quality Assurance/Improvement and/or Employee Health or public health/clinic experience preferred.
5. Experience or evidence of additional education in the area of Infection Prevention.
6. Working knowledge of nursing process.
7. Computer literate.
8. Effective communication skills.
9. Able to read, speak and write English. Bilingual English/Spanish helpful.

Transportation

1. Have a valid driver’s license, and automobile insurance as required by the State of Texas.
2. Personal vehicle available for transportation during working hours and access to telephone in home.
3. Process oriented.

WORKING CONDITIONS

1. Works in a well-lighted ventilated office area, as well as throughout the nursing service areas.
2. Subject to frequent interruptions.
3. Involved with physicians, patients, family members, personnel, visitors, government agencies/personnel, etc., under all conditions/circumstances.
4. Subject to hostile and emotionally upset patient’s family members, etc.
5. Willingness to work beyond normal working hours, and in other positions temporarily, when necessary.
6. Able to work independently and be flexible.
7. Subject to falls, burns from equipment, infectious diseases, odors, etc., throughout the workday.
8. Exposure Level II: Job does not routinely involve exposure to blood, body fluids, or tissues, but exposure or potential exposure may be required as a condition of employment.

PHYSICAL REQUIREMENTS

1. Sits, bends, lifts and walks intermittently during working hours.
2. Able to sit for prolonged periods.
3. Able to reposition up to 20 pounds of weight.
4. Possesses sight/hearing senses, or uses prosthetics that enable these senses to function adequately, so that the requirements of this position can be fully met.