Quality Coordinator | Patient Advocate (PART-TIME)
Cross Creek Hospital Together with Ascension Seton · Austin, TX, US
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About the Role
The Quality Coordinator is responsible for ensuring patient safety and superior quality of care as measured by survey readiness, treatment program fidelity, and compliance with state and federal laws and regulations and accreditation standards. The Coordinator oversees policy and procedure implementation, operational quality, critical incident reporting, regulatory engagement, and the quality assurance and process improvement (QAPI) program.
Responsibilities
- Assist the Director of Quality in monitoring day-to-day regulatory readiness, patient safety, and service excellence.
- Assist the Director of Quality with QAPI program oversight, including utilizing collected data for service improvement and conducting annual program preparation and evaluation.
- Complete process improvement projects and incorporate results into patient care improvements.
- Submit quality scorecard data to Acadia corporate office.
- Coordinate the abstraction of clinical data according to Joint Commission specifications and data entry for Inpatient Psychiatric Core Measures (HBIPS).
- Identify key aspects of care relevant indicators and evaluate data from feedback sources to improve management strategies and service delivery.
- Coordinate data collection and analysis from all departments.
- Prepare program data trends and action plans for Quality Council, Medical Executive Committee, and Governing Board meetings.
- Assist the Director of Quality in implementing sustainable survey preparation and ongoing monitoring processes, including facility-wide auditing and early-issue identification.
- Collaborate with other departments to implement best-practices in regulatory/accreditation compliance.
- Develop and maintain proficiency in electronic platforms such as electronic patient observations and the electronic medical record.
- Engage in and assist with timely evaluation of serious incidents, complaints, grievances, and related investigations.
- Develop corrective action plans for regulatory vulnerabilities or patient safety risks in collaboration with facility leaders.
- Ensure proper reporting of violations or potential violations to enforcement agencies.
- Assist with proper reporting of incidents and adverse clinical outcomes to regulatory agencies.
- Propose sustainable performance improvement practices through data analysis and prioritization.
- Ensure multidisciplinary ownership of best-practices in self-monitoring, auditing, and process improvement.
- Ensure operational implementation of regulatory requirements, guidelines, and standards.
- Serve as a technical advisor, educator, and internal consultant on performance improvement tools and techniques.
- Ensure facility compliance with policies and applicable standards.
- Serve as a visible, engaged, and dynamic member of the facility team.
- Review incident/safety concerns to identify systemic issues and facilitate corrective actions.
- Identify problems or potential problems to prevent risks to patients and staff.
- Propose corrective steps, which may include changes in policies/procedures, staffing, education, or services.
- Perform other functions and tasks as assigned.
Requirements
- Bachelor’s Degree in Human Services or nursing required.
- One or more years of experience in a Quality or PI role preferred.
- One or more years of management experience preferred.
- Experience with CARF, DEA, Joint Commission, or CMS surveys, as required by service line(s) supported.
- Current licensure appropriate for the degree held required.
- CPR and de-escalation/restraint certification required (training available upon hire).
Skills
- Quality assurance
- Process improvement
- Regulatory compliance
- Patient safety
- Data analysis
- Performance improvement
- Auditing
- Electronic medical record proficiency
- Joint Commission specifications
- Inpatient Psychiatric Core Measures (HBIPS)
Location
- Facility-wide
Work Type
- Full-time
Experience Level
- One or more years of experience in a Quality or PI role
- One or more years of management experience
Education Level
- Bachelor’s Degree in Human Services or nursing
- Master’s degree preferred
About the Company
- We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.
Equal Opportunity
- We are committed to providing equal employment opportunities to all applicants for employment regardless of an individual’s characteristics protected by applicable state, federal and local laws.