Job Summary
Executes activities for the following programs as directed by the Assistant Administrator Quality and Infection Control or designee: Quality and Performance Improvement, Patient Safety, Risk Management, Safety; collaborates with Quality and other leaders on survey readiness activities; conducts medical chart review, data abstraction and report preparation; serves as internal consultant to clinical departments on quality, performance improvement, patient safety and other related practices and processes. Requires a wide range of knowledge, skills and abilities in the healthcare profession, and is able to implement evidence-based practices and develop new approaches to improve regulatory compliance and patient outcomes.
Works with Care Leaders and Associates to problem solve and determine satisfactory solutions to achieve compliance, or developing suitable alternatives that will meet regulatory requirements aligned with the University Medical Center of El Paso’s (UMC-El Paso) mission and values.

Skills
1. Ability to apply knowledge of TJC, CMS, and regulatory accrediting agency standards to assure compliance.
2. Ability to communicate effectively; written and verbal skills required.
3. Ability to understand, use and teach the principles of performance improvement
4. Ability to evaluate quality issues and present data to other professionals in a clear concise manner.
5. Proficient in utilizing the principals of analytical assessment and creative problem solving.
6. Knowledge of hospital systems and organizational relationships.
7. Ability to use critical thinking skills to conduct research, and utilize interpersonal and problem solving skills.
8. Ability to organize, delegate, implement, and evaluate effectiveness of processes.
9. Ability to interview and work in teams.
10. Ability to use a computer and related software applications.

Work Experience
Three years of clinical experience as a Registered Nurse required. Experience with patient safety activities, clinical evidence-based practices and/or performance improvement preferred.

License/Registration/Certification
Current license to practice as a Registered Nurse in the State of Texas.
Certified Professional in Healthcare Quality (CPHQ) or other relevant certification preferred.

Education and Training
Bachelor degree in Nursing required. Master degree in Nursing preferred.