AK - RN Quality Management and Accreditation - LTC QAPI - Sitka

Long-Term Care QAPI Coordinator / RN

SEARHC is a non-profit health consortium which serves the health interests of the residents of Southeast Alaska. We see our employees as our strongest assets. It is our priority to further their development and our organization by aiding in their professional advancement. Working at SEARHC is more than a job, it's a fulfilling career. We offer generous benefits, including retirement, paid time off, paid parental leave, health, dental, and vision benefits, life insurance and long and short-term disability, and more.

Primary responsibilities are as the Long-Term Care (LTC) QAPI Coordinator / RN. The primary purpose of this position is to facilitate, conduct, coordinate, and evaluate consistent quality clinical care delivery through adopted clinical standards, policies, practices, protocols, and processes. Ensure compliance with CMS and other regulatory bodies, as applicable. This position coordinates regulatory surveys; continuous accreditation readiness activities. As a member of the LTC facility interdisciplinary team, this position also coordinates, assigns, performs and evaluates general practices within the facility as it relates to safety, regulatory compliance, corporate standards, and more using the QAPI program as one method of monitoring. Infection Control facilitation, as it relates to adopted and expected performance is aligned with this position. This position works closely with Administration, Providers, Leaders and Staff to ensure awareness of quality and patient safety, and to facilitate improvement efforts in all areas.

Key Essential Functions and Accountabilities of the Job May Include Any and/or All of the Below:

• Collaboration with the Long-Term Care Administrator on overall QAPI objectives for the organization.
• Plan, organize, and direct quality assurance program and activities.
• Lead projects and provide education and coaching and coordinate with directors/managers to ensure QAPI efforts are integrated into all operations and departments, including staff responsibilities.
• Provide ongoing assessment of performance, analyzes clinical outcome data, and identifies performance improvement opportunities or trends.
• Plan, develop, organize, implement, coordinate, and direct the quality assurance and assessment program designed to enhance the quality of resident care, in accordance with current rules, regulations, and guidelines that govern nursing care facilities.
• Establish and maintain tracking systems for recommendations of groups involved in quality assurance.
• Develop and implement appropriate plans of action to correct identified deficiencies.
• Assist in developing follow-up procedures for monitoring identified problem areas.
• In collaboration with the Risk Manager, perform RCA as necessary and keep all records of FRIs (facility reported incidents) and Datix events, and assist in investigations of incident reports, complaints, resident care issues and others as requested.
• Make written and oral reports and recommendations to the Administrator, as necessary or required, concerning the operation of the quality assessment and assurance program.
• Design a process for and conduct an evaluation of QAPI efforts (at least annually). Facilitate a discussion within the quality committee for this annual review.
• Develop and maintain formal QAPI plan.
• Organize and facilitate the quality committee meetings by guiding discussion around performance measures and prioritizing and developing quality efforts and maintaining meeting minutes.
• Participate in Facility's surveys. Review and write/revise policies and procedures, survey reports, facility wide assessment, etc.
• Communicates professionally and effectively with all levels of the organization; serves as a resource, mentor, and role model for others as QM is continuously integrated into everyday processes within the organization.
• Support the QMA Department with quality management responsibilities, to include, but not limited to; chart audits, rounding, accreditation readiness and support, participate and facilitate quality committees, as applicable.
• Other duties as assigned, including cross coverage of other QM Team member roles.

Education, Certifications, and Licenses Required

• Current full, unrestricted, active Registered Nursing license in Alaska.
• Direct Hire must have applied for an Alaska nursing license before the start date. Agency staff must have an active Alaska license.
• Certified Professional in Healthcare Quality (CPHQ), or QAPI Certified Professional (QCP), or other LTC Quality Certification, obtained within 3 years - required.

Experience Required

• 2 years' experience monitoring quality and regulatory requirements, planning, and coordinating process changes.
• Demonstrated experience that shows leadership skills in facilitating and leading cross-functional teams and in working collaboratively with groups or teams.

Knowledge, Skills, and Abilities

• Knowledge of accreditation requirements for a healthcare system to include long-term care, acute care, ambulatory and/or behavioral health.
• Strong working knowledge of patient care principles and practices
• Understanding of quality improvement concepts and practices
• Concepts around medical practice and standards of care
• General knowledge of organizational functions and operations.
• Knowledge of group processes and ability to lead processes.
• Skills in Experience with Data Analytics in the collection, analysis, and presentation of data
• Excellent verbal and written communication skills
• Skill with medical chart reviews and extraction of data
• Oral and written communication skills.
• Ability to focus and prioritize to attain goals.
• Effectively solicit ideas and information from individuals and groups.
• Ability to define problems, collect data, establish facts, and draw valid conclusions
• Computer Skills: Proficient in Microsoft Office Products including Word, Excel, and PowerPoint

Other Qualifications:

• Travel Required: Minimum of 30% travel is expected.
• Safety and Risk Management Responsibilities: Employees are responsible for complying with safe work rules; reporting all accidents and injuries immediately; cooperating in all accident and injury investigations; reporting defective equipment and unsafe conditions.
• Physical Demands: While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand; walk; sit; use hands to finger, handle or feel and reach with hands and arms. The employee is occasionally required to climb or balance; stoop, kneel, crouch or crawl. The employee may frequently lift and/or push/pull up to 25 lbs.
• Work Environment: The noise level in the work environment is usually moderate. The setting for this role will include office and healthcare settings. Exposure to controlled temperature environments, both hot and cold, is to be expected. The normal work routine involves no exposure to blood, body fluids or tissues. Persons who perform these duties are typically not called upon as part of their employment to perform or assist in emergency medical care or first aid or to be potentially exposed in some other way.
• Required Certifications: Basic Life Support (BLS) - American Heart Association, Clinical Competency Assessment - SEARHC, Registered Nurse License - our client Alaska - Alaska State Board of Nursing