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QAPI Coordinator

4 months ago

Gainesville GA, United States Northeast Georgia Health System Full time
Job Category:
Nursing - Registered Nurse
Work Shift/Schedule:
8 Hr Morning - Afternoon
Northeast Georgia Health System is rooted in a foundation of improving the health of our communities.
About the Role:
Job Summary
Responsible for the agency’s activities that attempt to ensure peak organizational performance and improve patient outcomes. Serves as a resource to clinical and administrative staff and affiliated providers in the areas of safety, infection control, compliance, state licensure, Medicare certification, CHAP accreditation and clinical standards of care and documentation. Serves as compliance officer. Provides Administrative On Call Coverage. Coordinates Quality Activities, Compliance Activities, and Emergency Operations activities with corresponding Corporate Departments.
Minimum Job Qualifications
  • Licensure or other certifications: Current Georgia nursing license.
  • Educational Requirements: Graduate from a state approved school of nursing. BSN required.
  • Minimum Experience: 3-5 years experience with Hospice voluntary accreditation processes including quality assessment and performance improvement concepts and processes preferred.
  • Other:
Preferred Job Qualifications
  • Preferred Licensure or other certifications: CHPN.
  • Preferred Educational Requirements: MSN.
  • Preferred Experience:
  • Other:
Job Specific And Unique Knowledge, Skills And Abilities
  • Excellent attention to detail, time management and organization.
  • Ability to analyze and correlate clinical care with regulatory requirements and accreditation standards to propose processes for ensuring compliance
  • Effective communication; positive interpersonal skills; team player
  • Conceptual problem solving
  • Self directed
  • Proficient in Emergency Preparedness Standards and Implementation
  • Proficient in M/C, M/A, State and CHAP Accreditation Standards and Regulations
Essential Tasks And Responsibilities
Develops and oversees QAPI (quality assessment performance improvement) component of the hospice program.
  • Coordinates and oversees quality assessment and performance improvement programs of the hospice program. Serves as chair of the QAPI and Peer Review committees, schedules meetings, documents and distributes minutes of these meetings.
  • Responsible for submission of Hospice Item Set and other required quality data to CMS.
  • Responsible for coordination of satisfaction surveys and quality initiatives for all clinical and data benchmarking with external benchmark vendors and state and national organizations in accordance with regulatory requirements and agency policy and procedure. Ensures timeliness deadlines are met.
  • Assists the Hospice Leadership Team in development of performance improvement plan and PI priorities. Develops and maintains department QAPI dashboard.
  • Reviews current and ongoing quality assurance and performance improvement activities. Reports unacceptable compliance findings to Hospice Leadership Team. Utilizes established outcome criteria, industry standards and all guidelines to recommend action plans to promote improvements and to ensure compliance in all areas.
  • Ensures annual evaluation of all contracted vendors and assists in development of plans and follow up action for any vendors not meeting performance expectations.
  • Conducts routine, ongoing audit of clinical chart documentation to ensure compliance with state and federal regulatory guidelines, accreditation standards and to ensure advancement toward desired outcomes/goals and clinical excellence
  • Recommends corrective/improvement activities based on conclusions drawn from audits and works closely with clinical supervisors to assure that problem areas are addressed and corrected.
  • Reviews all patient/family variances and complaints for regulatory issues and participates in corrective action planning. Processes variances and complaints per organizational policy. Immediately apprises the Hospice Leadership team of any Risk Management Issues.
  • Provides education and reports to clinical and administrative staff concerning QAPI activities, outcomes and improvement plans.
Monitors state, federal and accreditation regulations and standards and assists in educating staff in changes in the regulations. Assists with the survey process. Responsible for maintaining hospice clinical, administrative, infection control and safety policies and procedures assuring compliance with state and federal regulations and accreditation standards. Participates in the development of staff educational guidelines and standard work documents.
  • Acts as department compliance officer to oversee compliance activities. Provides timely information to Hospice Leadership concerning status of compliance with regulatory and accreditation standards.
  • Coordinates the logistics of the actual regulatory/accreditation visits/survey activities as appropriate.
  • Participates in the continuous survey readiness process for the hospice program
  • Utilizes established outcome criteria, industry standards and all guidelines to recommend action plans to the Hospice Leadership Team to promote improvements and to ensure compliance in all areas.
  • Assists in the development of protocols/procedures, guidelines, pathways, and educational materials.
  • Identifies need for creation or revision of policies and procedures. Reviews and updates policies, procedures and protocols on an ongoing basis and at least annually and manages implementation.
  • Coordinates the development, refinement and approval process in organization’s policy management system.
Provides Leadership And Performs Operational Responsibilities.
  • Participates on NGMC Infection Control Committee and others as appointed.
  • Participates in the preparation of annual agency evaluation.
  • Serves as a member of the Hospice Leadership Team.
  • Participates in the Administrative call rotation.
  • Performs other related activities and duties as requested.
Physical Demands
  • Weight Lifted: Up to 100 lbs, Occasionally 0-30% of time
  • Weight Carried: Up to 50 lbs, Occasionally 0-30% of time
  • Vision: Moderate, Frequently 31-65% of time
  • Kneeling/Stooping/Bending: Frequently 31-65%
  • Standing/Walking: Frequently 31-65%
  • Pushing/Pulling: Frequently 31-65%
  • Intensity of Work: Frequently 31-65%
  • Job Requires: Reading, Writing, Reasoning, Talking, Keyboarding, Driving
Working at NGHS means being part of something special: a team invested in you as a person, an employee, and in helping you reach your goals.
NGHS: Opportunities start here.
Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.