Job Description:DHR Health - US:TX:Edinburg - DaysSummary:FLSA STATUS: ☒ Exempt ☐ Non-ExemptMISSION STATEMENT:Our Mission is to improve the well-being of those we serve with a commitment to excellence: every patient, every encounter, every time.VISION:Our Vision is to create a world-class health system to advance medicine and increase access for the communities we serve by empowering caregivers to heal through compassion, knowledge, innovation, integrated care and excellence.POSITION SUMMARY:The Quality and Compliance Registered Nurse is responsible for assisting the Surgical and Procedural patient care staff in ensuring quality patient care and compliance with Texas Law, CMS, and The Joint Commission requirements through quality program design, data collection, analysis and presentation.POSITION EDUCATION/ QUALIFICATIONS:· Texas Registered Nurse (R.N.) license required· Graduate from an accredited Nurse Program· Current BLS Certification, ACLS preferred· CPHQ certification preferred· Must have good communication skills· Must have strong organization skills and be able to work independently.· Ability to communicate clearly and concisely with all levels of nursing, administration, and physicians· Ability to read, write and speak EnglishJOB KNOWLEDGE/EXPERIENCE:· Requires a proficiency level typically attained with three (3) years clinical nursing experience· Knowledge of Texas law and T JC regulations· Requires experience in performance improvement methodologies: quality measurement; and data analysis using statistical principles.· Working knowledge of quality improvement principles and methodologies utilized in health care.· An affirming style of leadership in working with others· Knowledge of adult education theory and practice and the ability to plan organize and lead educational sessions.Responsibilities:POSITION RESPONSIBILITES:· Promotes the facility mission, vision and values by effectively communicating them to others.· Considers mission, vision and values in developing services, standards and practices· Must maintain current knowledge of Texas law and T JC regulations.· Facilitates coordination of regulatory compliance activities that includes policy and procedure development, survey preparation, survey management and follow up, assessment of standards compliance and reporting of vulnerabilities to key stakeholders.· Commitment to the basic philosophy generally described in Total Quality Management (TQM) and ability to embody this philosophy in the work place.· Designs compliance studies, develops criteria for evaluation, and assists assigned hospital departments with appropriate data collection and data analysis.· Reviews and interprets patient care information, discharge summaries, operation reports, and other data sources used to assess quality care issues.· Creates reporting documents for departments to use for tracking compliance activities, trends and patterns and identifying opportunities for improvement.· Provides education on data analysis and utilization of information to clinical compliance and Joint Commission teams.· Attends and may facilitate department compliance meetings, providing input regarding problem identification and resolution, continuous quality improvement (CQI), and other patient care and accreditation activities.· May provide ongoing clinical support to Surgical and Procedural Area programs by reviewing and logging charts and incident reports, and recording improvement activities and results.· Assists with developing and maintaining effective comprehensive continuous compliance programs· Prepares reports for, and recommends research topics to the Quality Improvement Committee.· Develops record keeping and reporting functions and maintains appropriate files.· Develops effective data collection and evaluation tools to identify opportunities to improve patient care.· Assists with the establishment of tools to collect and organize data used in monitoring and continually assess the success of problem resolution activities.· Maintains Compliance Data, as required.· Completes and maintains records for problem status for follow-up.· Maintains and distributes corrective action reminder report to responsible persons.· Plans meetings and disseminates information to appropriate areas as directed.· Ability to assess and to explain data from broad perspective.· Demonstrates the ability to manage multiple tasks and projects in a productive manner· Demonstrates interdepartmental support and teamwork through a supportive and collaborative approach· Organizes, schedules and conducts internal audit process to measure survey readiness (mock surveys, tracers activities, etc.).· Tracks and trends regulatory compliance issues· Prepares quarterly leadership report regarding regulatory compliance· Coordinates Process Improvement· Coordinates PSI Indicator Initiatives· Coordinates all on site regulatory, licensure and accreditation surveys· Knowledge of PC technologies, including operating and application software· Educates hospital staff, medical staff and leadership regarding regulatory requirements/changes· Other duties as assignedLINES OF REPSONSIBILITES:(Chain-of-command)1. Director → 2. Vice President of Surgical Services → 3. Chief Executive OfficerOther information:CUSTOMER SERVICE:Provide excellent customer service to all DHR customers. All employees are required to attend the DHR C.A.R.E.S program which outlines the Customer Service Principals including: Commitment, Accountability, Respect, Excellence and Service.AGE SPECIFIC:Employees must be able to demonstrate the knowledge and skills necessary to provide care appropriate to the age of the patients served in his/her assigned unit. The individual must demonstrate knowledge of principles of growth and development over the life span and possess the ability to assess data reflective of the patient’s status and interpret the appropriate information needed to identify each patient’s requirement relative to his or her age.AMERICANS WITH DISABILITIES ACT: (ADA):A. Essential Duties: Indicated by bold print within performance standards, preceding individual numbered criteria.The following table provides physical requirements that will be associated with, but not limited to, this position:Light/moderate lifting up to 20 lbs, from the floor to shoulder height.YesKneelingYesMust be able to assist other employees with lifting more than 20 lbs.YesWalkingYesLight/moderate carrying up to 20 lbs.YesStanding/SquattingYesStraight pullingYesSittingYesPulling hand over handYesPushingYesRepeated bendingYesStooping/BendingYesReaching above shoulderYesClimbing StairsYesSimple graspingYesClimbing LaddersNoDual simultaneous graspingYesDepth Perceptions neededYesAbility to seeYesIdentify ColorsYesOperating office equipmentYesTwistingYesOperating mechanical equipmentYesCrawlingNoAbility to read and writeYesAbility to CountYesAbility to hear verbal communication without aidYesOperating Personal VehicleYesAbility to comprehend written/verbal communicationYesOther: Ability to deal with stressYesOSHA CategoryIIIB. Working Conditions: The individual spends over 95% of his/her time in an air-conditioned environment with varying exposures to noise. There is protection from weather conditions but not necessarily from temperature changes. The position does have low exposure to malodorous, infectious body fluids from patients and some minimal exposure to noxious smells from cleansing agents.C. Occupational Exposure: This position has minimal to no exposure to blood, body fluids, or tissues and is an OSHA Category III (although situations can be imagined or hypothesized under which anyone, anywhere, might encounter potential exposure to body fluids). Person who performs these duties are not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.D. Aptitudes: HIGH 1 2 3 4 5 6 LOWIntelligence: General learning ability: The ability to “catch on” or understand instructions and underlying principles. Ability to reason and make judgments. 3Verbal: Ability to understand meanings of words and ideas associated with them, and to use them effectively. To comprehend language, to understand relationships between words, and to understand meanings of whole sentences and paragraphs. To present information or ideas clearly. 3Numerical: Ability to perform arithmetic operations quickly and accurately. 2Spatial: Ability to comprehend forms in space and understands relationships of plane and solid objects. Frequently described as the ability to “visualize” objects or two or three dimensions, or to think visually of geometric forms. 2Form Perception: Ability to perceive pertinent details and objects or in pictorial or graphic material to make visual comparisons and discriminations and see slight differences in shapes and shadings of figures and widths and lengths of lines. 3Clerical Perception: Ability to receive pertinent details and verbal or tabular material. To observe differences in copy, to proofread words and numbers, and to avoid perceptual errors in arithmetic computation. 2Motor Coordination: Ability to coordinate eyes and hands to fingers rapidly and accurately in making precise movements with speed. Ability to make a movement response accurately and quickly. 3Finger Dexterity: Ability to move hands easily and skillfully. To work with fingers in placing and turning motions. 3Manual Dexterity: Ability to move hands easily and skillfully. To work with hands in placing and turning motions. 3Eye-Hand-Foot Coordination: Ability to move the hand and foot coordinately with each other in accordance with visual stimuli. 3Color Discrimination: Ability to perceive and respond to similarities or differences in colors, shapes, or other values of the same or different color. To identify a particular color, or to recognize harmonious or contrasting color combinations, or to match color adequately. 3I have read and reviewed my job description with my supervisor or designee and I understand the job I am expected to perform.If applicable certification will be completed within time frame of hire/transfer date.Employee Signature: Date: Transfer/Hire Date Effective: .
