Quality Assurance Registered Nurse (RN) – Surgery Center

Webster ASC is a brand-new multi-specialty surgical center located in the picturesque neighborhood of Lincoln Park. It consists of two operating rooms and two procedures rooms with room for future expansion. The RN Quality Improvement and Assurance Coordinator would be responsible for objectively and systematically assessing, monitoring, and evaluating ways to improve the processes that affect the quality of patient care. This role is responsible for ensuring compliance with quality reporting, physician peer review, infection/prevention, ASC by-laws, rules/regs of the medical staff, and regulatory standards.

Major Responsibilities:

Facilitation of physician peer review through the Quality Improvement Committee function:

• Preparation of agendas, minutes, reports, correspondence, and all follow-up issues.
• Ensures that the Committee is in compliance with all regulatory agencies, acts as a resource in this area.
• Perform confidential physician profile analysis for credentialing purposes.
• Initiate peer review, new physician review, and medical necessity review and prepare reports for the QI and MAC Committees.
• Observes strict confidentiality of all information pertaining to quality assessment and improvement activities and practices discretion and sound professional judgment at all times.

Performs quality assessment and improvement activities.

• Design and implement clinical studies to identify variation in medical management in order to improve patient care and outcomes.
• Ensures the QI operations comply with federal, state, and payer requirements. Stay current on standards/recommendations for regulatory agencies by attending seminars, conventions, and maintaining professional memberships.
• Conduct chart review and data collection.
• Nursing QA review, and review Anesthesia QA data forms.
• Provide statistical analysis and graphic representation of data.
• Compile monthly statistics/volume report per department and per physician.
• Conduct Infection Control investigation, follow up and reports.
• Review, investigate and report on Patient Satisfaction issues.
• Monitors and distributes gift cards for service recovery.
• Report quarterly to the Medical Advisory Committee (MAC).
• Serve as committee member on the CQI Committee and take minutes of CQI meeting.
• Coordinates and runs Code Blue/MH drills. Critique drills with staff and physicians.
• Provides education to staff on areas of improvement.

Conduct Infection Control Investigation, follow up and reports

• Facilitate education program for ASC physicians and associates. Schedule inservices as needed and maintain the inservice book.
• Maintain membership with APIC/ASCOI
• Investigate and follow up on a monthly basis all infections reported until the patient is released from the physician's care.
• Track and trend similarities. Report to QI MAC.
• Complete ICRA forms when new construction/repairs are being made on the ASC proper.Attain yearly CEU’s in Infection Control and Prevention
• Conduct IC/IP ASC/Endo reviews as identified by yearly infection control risk assessment. Report findings.

Act as Risk Manager:

• Receive, investigate, and perform follow-up activities on Occurrence Reports/STARS and hosptial admissions. Intitiates and completes ACA's as needed
• Report on the above to the QI Committee/MAC. submit end of year evaluation for risk management activities at the ASC to appropriate committees.
• Notify appropriate agencies and Administration as required to alert of potential at risk issue.
• Maintain sharps injury prevention program and log.
• Ensure yearly education is completed to all staff.
• Observe strict confidentiality on all issues pertaining to Risk Management activities. Keep OSHA log confidential.
• Provide staff in-services regarding the overall activities and programs of the QI/RM department.
• Responsible for the development of additional policies and procedures as needed to support the QI/RM function and regulatory requirements.
• Assists the Administrative Director of the ASC in dissemination of standards information and the coordination of survey visits by regulatory agencies.
• Keeps abreast of current trends in the field in regards to Risk Management, Infection Control, and Quality Improvement.
• Shares knowledge of current trends and standards and acts as a resource in these areas.
• Maintains records for product equipment recalls/warnings/and advisories.
• Ensures product evaluations are complete to provide information to the leadership team to make an informed decision.

Ensure compliance with Joint Commission and completion of regulatory studies.

• Maintain appropriate records for review by Joint Commission /IDPH. Including documentation of incomplete medical records.
• Responsible for overseeing, developing, and tracking studies in the 10 point Joint Commission format.
• Perform the yearly Joint Commission benchmark QI study.
• Ensure policies and procedures are updated and followed according to Joint Commission/CMS standards.
• Responsible for ensuring that the ASC follows the appropriate standards of care for infection prevention, safety, high level disinfection, sterilization, and environmental cleaning.
• Responsible for overseeing developing tools to obtain information to submit the required reports for the Ambulatory Surgery Center Quality Reporting Program.
• Ensure all records are complete in the ASC chart through chart audits.
• Provide on hire and yearly Risk Management in service to ASC employees.

Licensure:

• Nurse, Registered (RN)

Education/Experience Required:

• Graduate of an accredited school of nursing 4 years experience with QA programs.
• Experience with Risk Management is helpful.
• Preferrably have Certification in Infection Control (CIC)

Knowledge, Skills & Abilities Required:

• Good interpersonal, communication and presentation skills
• Working computer knowledge
• Good organization skills Knowledge in meaningful data collection
• Current license as a registered nurse in the State of Illinois

Physical Requirements and Working Conditions:

• Resilience and flexibility to deal with a changing environment
• Ability to work under stressful conditions and in difficult situations Innovative, self-motivated, detail-oriented
• If position has direct patient care or direct patient contact the following lifting requirement supersedes any previous lifting requirement effective 06/01/2015. Ability to lift up to 35 pounds without assistance. For patient lifts of over 35 pounds, or when patient is unable to assist with the lift, patient handling equipment is expected to be used, with at least one other associate, when available. Unique patient lifting/movement situations will be assessed on a case-by-case basis.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.