QA COORDINATOR

Summary/Objective

As a member of the Quality Assurance team, the Risk Management Investigator coordinates and completes daily internal reviews of clinical staff documentation, focused reviews, and problem identification. Coordinates the hospital’s Incident Management Program through comprehensive, objective investigation, data collection, analysis and reporting of patient related incidents.

• Uses discretion and confidentiality, at all times, with patient records; and uses discretion when discussing patient matters.
• Monitor, review, & analyze clinical documentation to assure the highest quality of coordinated care.
• Consistently demonstrates the ability to recognize establish, and deal with priorities promptly.
• Consistently offers to share information from seminars and meetings attended outside the hospital.
• Follows up in response to findings, ensuring all findings have been addressed.
• Provides a report tracking compliance with timeliness as mandated by applicable legislative and accrediting organizations.
• Always observant of safety, infection control, fire and safety, and Right to Know procedures.
• Reviews all incident reports and assesses the circumstances surrounding the incidents, conducts a preliminary investigation to assure appropriate actions were taken, and determines the appropriate level of investigation.
• Conducts all special investigations in a timely, objective, thorough manner.
• Communicates all important developments and findings from internal reviews to clinical supervisor and CQO.
• Identifies areas of risk and participates in the improvement of processes and out-comes.
• Prepares monthly reports of all patient incident types to identify and analyze trends as well as deviations.
• Reports at the monthly management meetings and QA/PI meetings.
• Assembles results of special incident investigation for review by the QA team.
• Serves as liaison with regulatory agencies and law enforcement agencies at the direction of CQO.
• Participates, as directed by CQO, in performance improvement, risk management, and utilization management activities.
• Prepares quarterly reports for Incident Management for presentation at the QA Performance Improvement Meetings.
• Keeps CQO informed of progress and major developments during investigation/s
• Convenes meetings of the Special Incident review committee and participates in the committee meetings to assure that incidents are appropriately reviewed, investigated and any corrective actions are implemented.
• Monitors corrective and/or preventative actions taken in response to recommendations of the Incident Management Committee.
• Notifies the CQO of any suspected incidents/occurrences which may require legal counsel.
• Prepares reports requiring external notification promptly in accordance with Brunswick Hospital’s Procedure for incident management.
• Maintains updated knowledge base of origins, characteristics, current treatment and management trends, psychiatric disorders and other related areas.
• Maintains updated knowledge in the field of Quality Assurance, Utilization Review, and Performance Improvement.
• Provides coaching and feedback to associates as necessary.
• Responsible for ongoing tracking of all necessary chart documentation.
• Assumes additional responsibilities at the direction of the Chief Quality Officer.

Competencies

• Attention to detail
• Communication skills - verbal and written
• Data collection, management and analysis
• Problem analysis and problem solving
• Planning and organizing
• Time management

Work Environment

This job operates in a psychiatric health care setting; which requires regular walking to various locations around the hospital. The incumbent will be intervening with psychiatric patients who may be unruly at times.

Position Type and Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday, 37.5 hours per week. Occasional evening and weekend work may be required as job duties demand.

Travel

No travel is expected for this position.

Required Education and Experience

• Bachelor’s Degree, Required
• 1-2 years of specific Behavioral Health clinical knowledge
• Proficient in Microsoft Office applications.
• Previous experience in behavioral health care preferred.
• Strong knowledge of OMH and JACHO regulations
• Demonstrated ability to identify trends and conduct root-cause analyses
• Ability to provide constructive feedback with a focus on improved quality
• Ability to communicate in a positive/professional manner both orally and written
• Ability to follow detailed instructions with a high degree of accuracy
• Ability to work independently; complete tasks in the allotted time frame
• Strong problem-solving skills and decision-making skills
• Available to work some evenings and weekends

Preferred Education and Experience

• Master’s Degree, preferred
• Certifications such as, Quality Auditor, Quality Engineer, Quality Improvement Associate, Six Sigma, preferred
• Quality inspection, auditing and testing experience

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