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Quality Management Coordinator

Wellstar Windy Hill Hospital • Marietta, GA • Coding, Compliance, and Health Information Systems • 111908 • Days • Part-Time


The Quality Management Coordinator is preferably a registered professional nurse, Industrial Engineer, or Healthcare Informatics professional who functions under the AVP/Director of Quality and Patient Safety and is responsible for providing leadership and assistance in facilitating activities/services for the quality program, including but not limited to Sepsis, Stroke, Heart Failure, PSI Review, HAC Review, Mortality Review, Quality Performance Improvement.

Key responsibilities of the Quality Management Coordinator include appropriate chart/data abstraction, analyzing and reporting, coordination of related departmental / service line functions, process improvement, physician, and staff education. The Quality Management Coordinator will assess and recommend modifications to workflows, using their clinical expertise and knowledge of operations to improve compliance with quality guidelines and help team members and providers to have greater customer focus. The coordinator will facilitate appropriate PI Committees and bring greater systems/analytic thinking to the team.

The Quality Management Coordinator must combine the roles of clinician, leader, liaison, educator, researcher, consultant, and quality improvement specialist to drive improvements in quality outcomes. They have shared responsibility for supporting adherence to standards of practices, system, and department policies and procedures, and ensuring quality patient care. Other responsibilities include assisting with ensuring compliance with regulatory and legal requirements by all team members, visitors, and providers.


Core Responsibilites and Essential Functions

  • Quality Improvement Data Review, depending on the specific assignment of the team member
    * Completes daily review of relevant cases, deaths, and safety events related to sepsis, as needed.
    * Reviews HAC (Hospital Acquired Conditions), Mortalities and relevant AHRQ Patient Safety Indicators for opportunities for improvement, as needed.
    * Participate in mortality and patient safety reviews to identify preventable clinical harm and help work with team members to put processes in place to improve outcomes.
    * Assists in the completion of timelines for precursor, serious safety, and sentinel events including but not limited to Quality area of focus such as Sepsis, PSIs, etc.
    * Completes chart reviews for regulatory and accreditation audits as directed.
  • Promotes and actively participates in performance improvement initiatives designed to enhance quality patient care and improve work processes and efficiencies for quality improvement area of focus.
    * Partners with physicians, managers, and staff to ensure maximum quality and value of clinical care through individual accountability, identification, and implementation of process improvement efforts.
    * Empowers shared decision by fostering teamwork, open communication, and inclusion of diverse thought.
    * Researches and presents ideas on improvements in the areas of quality improvement care, reporting and clinical services.
    * Uses problem solving and communication skills to bring forth performance improvement ideas and opportunities.
    * Uses established Performance Improvement criteria when addressing issues or recommending changes in practice, policies, and procedures.
    * Gemba quality processes to determine areas of opportunity and identify actions to fill gaps.
    * Serves as the Subject Matter Expert and facilitator for the designated Performance Improvement Committee, a subcommittee of the Quality Review Committee.
    * Analyzes data for quality improvement
    * Uses lean and other quality skills to reduce waste and improve performance of operations and clinical systems of care; integrates marketing and communication strategies to advance service lines and the organization.
  • Patient Care Effectiveness
    * Provides clinical expertise to nursing staff as well as patients and their families.
    * Coordinate?s care for various patient populations, including geriatric or pediatric patients, and ensure that protocols are age appropriate.
    * Develop and give input on the development of clinical tools like standing orders, bundles, nurse-driven interventions, clinical decision support apps, etc. to ensure continuity and quality of care.
    * Evaluates the feasibility of clinical outcome early warning and response systems.
    * Give input on nursing documentation standards and ensure compatibility with the existing EMR-.
  • Resources and Support
    * Engages leaders in decision-making and partners with others to promote patient centered care and service excellence while effectively providing leadership and management skills; possesses strong and effective negotiation and mediation skills.
    * Serves to support clinical and non-clinical leaders to promote the effective running of the care delivery system and ensures that the clinical processes of care are working as intended.
    * Serves as a resource for all physicians and leaders and accepts additional leadership responsibilities.
  • Interdisciplinary Teamwork and Collaboration
    * Effectively communicates to diverse audiences on nursing, health care and organizational issues and this includes the ability to set standards and holds leaders and staff accountable for performance standards related to sepsis care.
    * Proactively establishes a healthy workplace by reducing unnecessary conflict - resolves it when necessary ? promotes and achieves positive team dynamics.
    * Establishes partnerships by employing strong relationship building skills with all hospital leaders and medical staff by striving to understand others (and situations) and keeping the long view in mind ? is fair and just using reflective practice skills to monitor self and leader performance/interaction skills exercising coaching and guiding skills.
    * Creates opportunities for self and leaders to grow
  • Evidence Based Practice and Research
    * Effectively identifies areas of improvement of leaders and clinical systems and sponsors projects to improve the same. Includes assuring nursing division meets or exceeds licensure, regulatory and accreditation standards.
    * Applies the effective use of data and evidence to support decision making for clinical and operational responsibilities and demonstrates awareness of legal and ethical issues related to patient and staff data, information, and confidentiality

Required for All Jobs

  • Performs other duties as assigned
  • Complies with all WellStar Health System policies, standards of work, and code of conduct.


Required Minimum Education

  • Bachelor's Degree in nursing (BSN), Industrial Engineer, Healthcare Informatics, or healthcare related field Required and
  • Master's Degree in related field (e.g., MSN, Healthcare Quality, Public Health, etc.) Preferred and

Required Minimum Experience

  • 5 years experience of clinical or performance improvement experience in nursing and/or clinical quality in a hospital or health system. Required and
  • Training as a Clinical Nurse Specialist Preferred

Required Minimum Skills

  • Advanced clinical knowledge and skills in the field of practice.
  • Demonstrates knowledge of standards related to the field of practice.
  • Inter- and intradepartmental coordinator of patient care activities
  • Strong detail orientation required.
  • Adept as a change agent. Utilizes a wide range of theories in managing complex problems or problem resolution.
  • Ability to use critical thinking skills to identify barriers and opportunities.
  • Exceptional interpersonal, team building and communication skills.
  • Ability to build consensus and foster change in organizational setting.
  • Commitment to personal and professional growth
  • Sense of responsibility to self, team, and project
  • Outstanding integrity, initiative, creativity, and passion
  • Ability to perform duties and responsibilities with minimum direct supervision.
  • Ability to review and analyze data/metrics from multiple sources, compiling and synthesizing these data.
  • Strong computer skills, including proficiency in Word, Excel and Power Point Visio and Outlook.
  • Excellent organizational, project management, and verbal/written communication
  • Must be comfortable interacting with and sharing data results with physicians and team members at all levels of the organization and speaking in front of small to medium sized groups.

Required Minimum License(s) and Certification(s)

Additional Licenses and Certifications

  • Georgia license (RN) or Lean certification Preferred
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