Quality Clinical Safety Coordinator - Quality Mgmt​/Clinical Safety

Job Objective

Under the direction of the Manager of Quality and Clinical Safety, this position is responsible for coordinating quality clinical safety activities, as part of the Performance Improvement (PI)/Quality Management (QM) and Clinical Safety (CS)/Risk Management programs (RM). Activities include patient care processes, outcomes, organizational functions, data collection, and regulatory preparation.

• Participates in the design and development of multidisciplinary and interdisciplinary processes to support and address the situation or issue such as Quality Improvement (QI) initiatives or Teams.
• Facilitates multidisciplinary teams and provides direction to enhance effectiveness.
• Contributes to the development and continuous improvement of organizational systems that support the performance improvement and risk management programs.
• Completes focus review or other quality studies and reports for presentation to QM, Medical Staff and/or other Hospital Committee meetings.
• Fosters organization systems that support implementation of the CS Plans and RM Plans.
• Supports clinical safety activities and functions.
• Develops statistical reports and conducts data analysis as part of the QI cycle.
• Acts as a member and representative for organization committees, including Medical Staff Department or Performance subcommittees, as assigned.
• Reviews and analyzes sentinel events/near misses with appropriate medical and/or hospital staff.
• Conducts case summaries, analysis, and preparation of timelines and succinct written reports for QM or RM.
• Coordinates and conducts intense analysis and ensures timely follow‑up of activities.
• Assists and supports the peer review process including Ongoing or Focused Professional Practice Evaluation studies.
• Uses the results of evaluation analyses to make or recommend process or structural changes, including policy, procedure, or protocol documentation, as appropriate.
• Implements initiatives to evaluate the need for change.
• Contributes to the development and continuous improvement of organizational systems that support the planning process.
• Analyzes and trends reports from the Patient Safety Electronic Event Reporting program. Collaborates with staff to complete follow‑up investigation as needed.
• Coordinates follow‑up responses to 3rd parties and as back‑up to the Director for patient grievances and other communication with Patient Guest Relations.
• Supports the Regulatory Coordinator in the direction of Clinical Safety functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff with emphasis on clinical safety.
• Assists the director in providing staff education on QM, CS, or RM topics.
• Works with Regulatory Coordinator in the direction of QM and RM functions of facility to meet Regulatory and Accrediting requirements for hospital staff and medical staff.
• Manages, aggregates, and reports information derived from the hospital‑wide event reporting system and/or other sources.
• Refrains from disclosing confidential information acquired in the course of work except when authorized, unless legally obligated to do so.
• Refrains from using or appearing to use confidential information acquired in the course of work for unethical or illegal advantage either personally or through third parties.
• Refuses any gift, favor or hospitality that would influence or would appear to influence actions.

• Other duties as assigned by the Director of Quality Management, Clinical Safety and Infection Control.

• Current knowledge of QM and CS principles.
• Knowledge of Regulatory and Accrediting bodies such as CMS, JC, State Department of Health and insurance providers.
• Maintains an appropriate level of professional competence by ongoing development of knowledge and skills.

• Strong communication skills to include group presentations.
• Skill and ability to follow the established Customer Service Expectations and Standards.
• Computer skills to include data entry. Working knowledge of MS Office Professional (Outlook, Access, Excel, PowerPoint, and Word).
• Demonstrated expertise in systems analysis and…