Quality Improvement Nurse

Quality and Performance Improvement Monitor, analyze, and report daily clinical performance data, trends, and outcomes. Performs daily rounding on the units to identify performance gaps and recommend evidence-based interventions as appropriate. Assist with developing, implementing, and evaluating quality improvement initiatives to enhance patient care and safety. Assist with ongoing quality improvement initiatives to improve resident care outcomes, reduce hospitalizations, and support five-star quality measures. Conduct data analysis on incidents, falls, infections, pressure injuries, medication errors, and other quality indicators. Facilitate root cause analysis and develop corrective action plans. Maintain accurate documentation of QI activities, results, and action plans. Utilize Electronic Health Records (EHR), other systems, and quality databases, to track and trend performance outcomes. Assist with the facilities Quality Assurance and Performance Improvement (QAPI) program, document meeting minutes of QAPI projects, and present findings to the Quality Assurance (QA) committee. Compliance/Risk and Safety Conduct regular audits to ensure compliance with organizational policies and external regulatory standards, for example Centers for Medicare and Medicaid Services (CMS), The Joint Commission. Review medical records for accuracy, completeness, and adherence to protocols. Ensure compliance with CMS regulations, state survey requirements, infection control standards, and facility policies. Participate in surveys, prepare required documentation, and support corrective action plans. Conduct audits such as medication pass, infection control rounds, and chart reviews. Collaborate with Interdisciplinary Teams (IDT) to improve workflow efficiency and patient care processes. Participate in committee meetings, Risk Management and Quality Assurance (RMQA), and other meetings as required. Support staff by delivering expertise in QI processes and patient safety initiatives. Provides training, coaching, and real-time feedback to clinical staff regarding documentation standards, care protocols, and compliance expectations. Contributes to fostering a culture of quality, safety, and accountability throughout the care continuum. Clinical Support Assists with policy and procedure updates to ensure evidence-based and regulatory-aligned practices are maintained. Weekend and off-hour rounding to ensure full compliance with clinical operations on a 24/7 basis. May be required to assume clinical staff coverage on the unit during periods of staffing challenges. Performs all other duties as assigned. SUPERVISORY RESPONSIBILITIES This role may provide supervision to team members on a situational basis. This position requires a background screening through the Care Provider Background Screening Clearinghouse. For information on the requirements, please visit the Clearinghouse Education and Awareness website at #J-18808-Ljbffr