CHA Hollywood Presbyterian Medical Center
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Clinical Quality Program Coord, RN
at CHA Hollywood Presbyterian Medical Center
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CHA Hollywood Presbyterian Medical Center
CHA Hollywood Presbyterian Medical Center (HPMC) is an acute care facility that has been caring for the Hollywood community and surrounding areas since 1924. The hospital is committed to serving local multicultural communities with quality medical and nursing care. With more than 500 physicians representing virtually every specialty, HPMC strives to distinguish itself as a leading healthcare provider, recognized for providing quality, innovative care in a compassionate manner.
HPMC is part of a global healthcare enterprise which owns and operates general hospitals throughout Korea, numerous fertility and research centers in the U.S. and Korea including CHA Fertility Center, a medical university, and CHAUM (a premier anti-aging life center).
Clinical Quality liaison function to ensure compliance in the implementation, maintenance and evaluation of evidenced based patient care. Uses clinical judgment and experience to assist in the coordination of assigned patient care quality management activities. Identifies and evaluates appropriate metrics to report to internal and external stakeholders. Collaborates with interdisciplinary staff and stakeholders throughout the institution to ensure recognized industry standards are utilized. Responsible for ensuring the facility is in compliance with TJC and clinical quality Core Measures, performs concurrent and retrospective clinical and regulatory review and in-depth analysis of patient records to assess organizational performance. Interacts with physicians, nursing, and ancillary staff to promote accurate documentation. Acts as a clinical resource person to the medical staff, hospital staff and relevant stakeholders. Other duties as assigned.
- Lead Nurse Clinical Quality Liaison for the organization’s Clinical Core Measures, other clinical and operational process improvement initiatives as assigned. Performs detailed, concentrated clinical and regulatory review with limited supervision.
- Identifies, at the earliest opportunity, any Core Measure regulatory changes that may impact the organization and make recommendations of how compliance can be achieved.
- Communicates (effectively verbally and in writing) with physicians, nursing staff, and all other customers involved.
- Uses problem-solving skills to proactively take action on individual cases not meeting measure requirements.
- Serves as a clinical quality resource for nursing and other clinical personnel, physicians, and other ancillary departments.
- Prepares reports for various stakeholders as assigned. Able to tailor data and reports to intended audience with minimal supervision.
- Communicates relevant information to appropriate department managers, provides follow-up to ensure new standards are being met. Tracks elements of action plans to ensure timely monitoring and prepares reports as requested.
- Communicates and interacts with physicians professionally and effectively.
- Screens medical records utilizing pre-established, pre-approved criteria as part of the Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation when applicable, as assigned.
- Ensures the integrity of data being reported and utilized.
- Designs and develops dashboards, presentations, educational materials relevant to the clinical audience.
- Demonstrates clinical and professional judgment in case referral determination.
- Maintains an accurate knowledge of clinical quality measures and the outcomes to be achieved.
- Provides assistance and support for patient care tracers as assigned.
- Exhibits flexibility to learn new areas, expanding clinical, professional, regulatory and technical knowledge and skills.
- Maintains confidentiality of information at all times.
- Graduate of nursing program: Diploma, Associate degree, or Baccalaureate program
- Bachelor’s degree from an accredited four-year college or university preferred
Minimum Work Experience and Qualifications:
- A working knowledge of hospital policies and procedures.
- Analytical and statistical skills to design internal audits.
- Ability to present pertinent data and recommendations clearly and concisely in a manner appropriate to end-user audience(s).
- Previous success in developing and implementing new practices and controls (with specific improvements)
- Previous inpatient nursing experience required.
- Ability to communicate effectively verbally and in writing.
- Ability to present ideas in a user-friendly language.
Preferred Work Experience and Qualifications:
Required Licensure, Certification, Registration or Designation:
- Unrestricted California Nursing License required
- Current LA County Fire Card
Disclaimer, Compliance and Service Language:
DISCLAIMER: The above statements are intended to describe the general nature and level of work being performed by incumbents assigned to this job. This is not intended to be an exhaustive list of all the responsibilities, duties and skills required. The incumbent may be expected to perform other duties as assigned.
COMPLIANCE & INTEGRITY: Consistently supports compliance and the Hollywood Presbyterian Medical Center's Code of Conduct by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licensure requirements (if applicable), and Hollywood Presbyterian Medical Center's policies and procedures.
Models and reinforces ethical behavior in self and others in accordance to the Code of Conduct; adheres to organizational policies and guidelines; supports compliance initiatives; maintains confidences; admits mistakes; conducts business with honesty; shows consistency in words and actions; follows through on commitments. All Directors, Managers and Supervisors are accountable for communication, implementation, enforcement, monitoring and oversight of compliance policies and practices in their departments.
SERVICE & QUALITY: In addition to defined technical requirements, accountable for consistently demonstrating service behaviors and principles defined by the Hollywood Presbyterian Medical Center, as well as specific departmental/organizational initiatives. Also accountable for consistently demonstrating the knowledge, skills, abilities, and behaviors necessary to provide superior and culturally sensitive service to each other, to our patients, and to purchasers, contracted providers and vendors.
WORKPLACE SAFETY: In addition to defined working conditions and physical requirements, employees are accountable for working safely; following established policies & procedures; utilizing all designated protective personal equipment (PPE) and/or safety equipment assigned for task; and reporting all injuries and hazards to their supervisor immediately. Supervisors and Managers are accountable for ensuring the safety performance of employees; applying consistent practices in compliance with federal, state and local regulations; providing guidance to maintain a safe and healthy work environment.