Responsibilities

• Works with The Joint Commission (TJC) standards, core measures, CMS regulations and National Patient Safety Goals (NPSG) to assist the departments in the development and implementation for related process and achieve improvement in compliance.
• Concurrently and retrospectively reviews compliance with national quality indicators and supplies. Reports to various committees and departments to ensure compliance and to improve patient care.
• Promotes risk management functions by completing peer review worksheets for departmental QM meetings.
• Works with medical staff committees to provide quality data to aid the committees with development of plans for opportunities for improvements.
• Works with staff/physicians to proactively intervene and achieve compliance with goals.
• Participates in the Quality Steering Committee and Quality Leadership Committee to find opportunities for improvement and to promote quality projects and teams.
• Works with PI teams to function as a facilitator with acquiring data sets and benchmarking data to assist the team in meeting their goals.
• Communicates to departments and committees noncompliance issues and works with the individual department leadership to assist them in the development of improvement strategies.
• Promotes quality measure awareness throughout the hospital through education opportunities through newsletters, posters, staff education, memos and other educational tools.