Summary

 While upholding the Star Valley Health mission, vision and values this position is responsible for working in

collaboration and partnership with hospital providers, directors and staff , provide daily monitoring and corrective

oversight for clinical Quality & Patient Safety initiatives, patient/family experience initiatives, scope of service

performance improvement initiatives, and utilizing clinical research and evidence-based practice information to

create, implement, and standardize clinical care pathways that are multidisciplinary in focus.

This is an “at will” position.

Job Duties

Patient Safety Event Management

• Promotes a culture of safety by encouraging transparency and open communication among staff to report safety events without fear of reprisal.
• Collects and evaluates data on patient safety events by interviewing staff and/or providers, reviewing medical records, and examining the environment or equipment involved.
• Collaborate with organizational and departmental leaders to identify contributing factors and develop actionable recommendations to prevent recurrence, ensuring follow-up communication with involved staff and monitoring implementation and effectiveness of corrective actions.
• Maintains objectivity and confidentiality of information related to provider and clinical documentation investigations or review.

Patient Concerns and Service Recovery

• Addresses patient concerns, complaints, and grievances promptly and empathetically, providing service recovery including apologies, explanations, and solutions implemented to prevent recurrence.
• Quality & Patient Safety Program Support
• Works collaboratively with the VP of Quality and Patient Safety to support departmental projects and the development and implementation of improved quality and patient safety reporting measures.
• May train and provide direction to staff on quality and patient safety related data and process issues.

Quality Software System Management

• Monitors quality software system performance, diagnoses issues, and maintains system configurations to ensure the system operates efficiently and effectively.
• Maintains the quality software system including, but not limited to, user access and training, data maintenance, interface connection and reliability, module workflows, focus studies (build and maintenance), report creation and maintenance, abstraction guidance and integrity, harvest file creation, management of data, and management of statit scorecards.
• Assists in validating system and program data, interface connections, and reliability, ensuring accuracy of data.
• Educates directors and other staff as needed on the quality software system.

Data Management and Reporting

• Reviews patient charts and other health information documents to obtain, verify, and enter information into the quality/risk management software.
• Reviews data for discrepancies, interacts with data managers, creates analysis datasets, and devises methods and procedures for collecting and validating data to ensure accuracy.
• Designs and generates reports within the EMR system to support the needs of the organization, providers, and administrators.
• Maintains charts and records for program documentation compliance.

Regulatory and Other Duties

• Assists in preparing regulatory documents.
• Performs other duties as assigned.

Abilities & Skills:

• Excellent written and verbal communication skills and attention to detail.
• Demonstrated human relations and effective communication skills.
• Demonstrated ability to prioritize tasks and determine the order of importance.
• Demonstrated knowledge of statistical analysis and medical terminology.
• Ability to make independent decisions regarding appropriate action plans.
• Ability to perform the essential functions of the job as outlined in the position description.
• Hours of Work: Monday through Friday 8 am to 5pm (may include extended hours and weekends)
• Travel: 5% to 10%

Physical: Mobility to work in a typical office setting and use standard office equipment, vision to read printed materials and screens, and hearing and speech to communicate effectively in-person and over the telephone. Strength and agility to exert up to 20 pounds of force occasionally and/or an eligible amount of force frequently or constantly to lift, carry, push, pull or otherwise move objects. Able to walk moderate distances.

Experience & Education:

• Registered Nurse, Respiratory Therapy, or comparable license required
• Minimum of three (3) years’ experience collaborating with organizational team members and providing monitoring and oversight of established organizational quality & patient safety, performance, safety, and regulatory initiatives. (preferred)
• Minimum of three (3) years’ experience performing audits to ensure ongoing regulatory compliance. (preferred)
• Knowledge in critical access hospital, accountable care organization, long term care, and/or related regulations and data requirements.
• IT and programming experience
• Midas Software experience

Note: Position descriptions are intended to serve as a guideline for typical duties and requirements of a position but are not inclusive. Additional or different responsibilities within a reasonable scope of the position description may be added or deleted any anytime at the discretion of the Board.