The Quality Nurse is a key member of LCHC's quality team to promote safe healthcare, to strengthen operational quality, and to ultimately improve clinical outcomes for our patients. The Quality Nurse is responsible for quality assurance and improvement in these areas:
1. Infection Control
2. Medical Assistant Clinical Competency and Training
3. Clinical quality reviews of providers and documentation by other clinical programs
4. Quality management of results
a. Oversight of the processes for reporting results to regulatory agencies
b. Oversight of the clinical processes regarding the follow-up of abnormal results.
5. Quality assurance and Quality Improvement project management as directed by the Medical Director of Clinical Quality or the Nursing Director.
Principal Duties and Responsibilities
1. Leads the infection control committee. Develops annual infection control plan, surveillance plan, and maintains organizational compliance with Joint Commission standards.
2. Plans, organizes, develops and implements educational programs for all clinic employees to increase employee awareness of existence of risks for infection; techniques for avoidance and preventive measures to provide a safe environment for employees and patients.
Medical Assistant Competencies and Training
1. Oversees development and implementation of clinical competencies for Medical Assistants, including initial orientation competencies and bi-annual competency validations.
2. Clinical support to site managers to facilitate the Medical Assistant orientation process
3. Coordinates periodic clinical training, i.e. in-services, for medical assistants
Clinical Quality Reviews
1. Performs chart audits of provider documentation and quality of patient care. This includes audits of new providers, annual lifecycle reviews, and any other audits needed to evaluate clinical quality issues.
2. Supervise and manage the provider self/peer chart review process.
3. Supervise and manages compliance for the midlevel collaboration/supervision process.
4. Perform clinical chart reviews needed for compliance with TJC clinical standards, e.g. the surgical chart reviews.
5. Prepares reports for the provider evaluations, for CQIC review, and for distribution to providers.
Quality Management of Results
1. Result Reporting: Manages process for results reporting to the State and other agencies as required by law or directive
a. Manage reporting to state for GC/Chlamydia
b. Manage reporting to state for all other communicable diseases (using report)
2. Abnormal Results management
a. Oversees clinical aspect of tracking/assuring management of positive or abnormal results (mammograms, paps, STD, etc.) in cooperation with care management staff performing this function.
b. Oversees clinical aspect of process of sending results letters to patients.
i. Manages process for sending lab letters to patients for normal or abnormal labs.
ii. Works with Health Support and Medical Directors to tie in content of mailing to HPOS and preventative care measures
Quality Assurance and Quality Improvement Projects
1. Quality Assurance: Leads investigations of assigned clinical incident reports, including coordinating a root cause analysis as needed. After the investigation, responsibilities include working toward development of action plans and monitoring implementation and maintenance of the corrective actions.
2. Quality Improvement:
a. Manages assigned clinical process/performance improvement projects to improve a clinical process, e.g. projects toward LCHC achieving Patient Center Medical Home certification.
b. Assists providers in Quality Improvement projects for maintenance of board certification. Keeps records of all projects, including results. Facilitates obtaining needed reports to define and evaluate projects.
c. Assists the Medical Director of Clinical Quality and the Director of Nursing with other QI projects as needed.
Required Skills or Abilities
Training or experience in clinical quality administration in a healthcare setting. Excellent clinical, organizational, managerial, and computer skills. Experience in infection control and clinical quality improvement projects desired. Prior leadership in these areas highly regarded. Certification in infection control beneficial.
Required Knowledge, Experience, or Licensure/Registration
Bachelor's in Nursing or higher clinical degree.