Clinical Quality Specialist in Kearney, Nebraska at Bryan Health

The Clinical Quality Specialist promotes optimal care to patients in the medical center through clinical activities, professional and public education, patient education, and performance improvement activities and functions. Helps to coordinate and facilitate the interdisciplinary needs of the patient and their family and assures coordination of pertinent quality improvement activities occurring throughout the organization.

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.

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.

In addition to the principal job functions contained on the primary job descriptions, the following duties are also required in the department noted above.

Accreditation

1. Serves as primary liaison with regulatory and accreditation bodies such as ACHC & CMS. 

1. Coordinates program-specific certification preparations with directors and staff responsible. 

1. Meets or exceeds ACHC and other regulatory and accreditation standards.

1. Works collaboratively with organizational and external stakeholders to complete licensure applications and maintain accuracy of licenses for KRMC.

1. Completes annual organizational and system AHA surveys with support and validation of leaders in the organization.

1. Provides leadership and participates in improvement initiatives and teams assigned.

1. Maintains current knowledge of regulatory and accrediting agencies requirements and ensures that requirements are addressed on an ongoing basis. 

1. Maintains current knowledge of applicable federal and state accreditation standards, and monitors advancements to ensure organizational adaptation and compliance. Communicates regulatory and accreditation changes as appropriate. 

1. Implements the Medical Center Corporate Compliance Plan; assists with review of the Medical Center’s plan for Patient Care Services and recommends adjustments. 

1. Assists in the development and implementation of the facility quality and safety plan. 

1. Organizes and serves as the facility host for regulatory and accreditation guests. Develop follow-up plans and responses for all regulatory and accreditation findings. 

1. Serves as internal consultant to senior management, medical staff and hospital departments in all matters related to regulatory agency standards and compliance. 

1. Reports on progress, results or barriers preventing successful implementation of projects to Director.