19 Nov QAPI/Employee Health Coordinator

Integrates and coordinates the hospital wide quality assurance performance improvement functions of the hospital and medical personnel. Works in conjunction with the infection control committee and performs surveillance throughout the hospital and Rural Health Clinic to identify, investigate, and record data concerning nosocomial infection rates, and other items that are utilized with infection control. Works with governmental agencies performing reports required by these agencies. Initiate infection control procedures and measures as directed by the Infection Control Committee, governing body, as well as government agencies. Assess needs, plans, organizes, coordinates, and implements the Employee Health program. Interpret policies, initiates, and updates policies, sets objectives, guidelines, and advises and counsels supervisory and non-supervisory personnel regarding Employee Health, infection control, and quality assurance and performance improvement. Provides leadership and chairs the Nursing Peer Review Committee.

Should have a working knowledge of epidemiology and infectious disease to monitor the infectious disease programs. Should have working knowledge of Quality Assurance and Performance improvement with the ability to manage the Quality Assurance Performance improvement program. Knowledge in risk management and patient safety with the responsibility for knowing the Centers of Medicare and Medicaid Services and Department of State Health rules and standards in all aspects of the job. Knowledge in employee health and well-being with the responsibilities for the employee health program and maintaining the employee health files meeting the rules and regulations required. 

Should have a working knowledge of Critical Access Hospital Conditions of participation pertaining to job functions. Should have knowledge of Nursing Peer Review.

Reports to: Chief Nursing Officer

Supervises: None

Essential Functions

1. Knowledge of epidemiology and infectious disease.
2. Knowledge of Centers of Medicare and Medicaid Services rules and standards on quality assurance and improvement, infection control, and employee health.
3. Maintain positive and effective relationships with district employees, departments, and Medical Staff. 
4. Maintain open communication and problem-solving atmosphere with other departments to achieve quality patient care, meet standards of practice, and required rules and guidelines for Critical Access Hospitals.
5. Coordinates, leads, and attends Quality Assurance Committee meetings including but not limited to keeping all records, reviewing data, and maintaining and recording minutes.
6. Assists the medical, nursing, department leaders, and other professional personnel in the development of QAPI Programs including monitoring indicators of care.
7. Promote consistency in quality assurance performance improvement activities on a hospital-wide basis to minimizes duplications of efforts.
8.  Reviews QAPI reports and refers information to appropriate committees, departments, services, and/or individuals for information to use as indicators and performance improvement guides.
9. Tracks QAPI problems and activities to ensure actions are being taken and improvement is not lost in the system.
10. Prepares QAPI reports for Administration and Governing Body.       
11. Provides Quality Assurance and Performance Improvement Education and training for departments. 
12. Assesses positive culture reports to determine infections present, nosocomial infections or community acquired infections.                                       
13. When appropriate assess patient records that hold a risk for nosocomial infections or increased spread of infections including but not limited to temperature charts, symptoms, cultures, discharge dispositions, follow-ups.
14. Assesses patients with potential sources of contamination and nosocomial risks including, but not limited to (IV’s, Foley Catheters, Incisions, Drainage, etc.)
15. Provides Infection Control Committee with reports including but not limited to type of infections, numbers of infections and problems encountered.
16. Ensures that environmental and personal cultures are obtained as appropriate and oversee any corrective actions needed.
17. Ability to compare laboratory reports to identify conditions that require infection control procedures. 
18. Adviseand consult with physicians, nurses, and hospital personnel concerning precautions to be taken to protect patients, staff, and other persons from possible contamination or infections.
19. Reports communicable or contagious diagnoses to the appropriate agencies.
20. Maintains infection control policies and procedures and assists with providing education and training.
21. Assures Employee Health Program meets required standards and are provided for employees.
22. Supervises the maintenance of employee health profiles. This includes maintaining and reviewing Employee Health Records for new and existing employees as determined by policy and conditions of participation.
23. Manage availability of first aid treatment for employees.
24. Consults with employees and or the Employee Health Physician regarding any problems or further follow-up needed for employees.                                    
25. Administers vaccination programs required by Employee Health Policies and Procedures and Infection Control Policies and Procedures.
26. Reviews equivocal TB skin test results and refers positive testing employees for chest x-rays and appropriate follow-up with public health department personnel. Follows established policies.
27. Ensure that new employees undergo new employee workups prior to working.
28. Ensures employees are provided medical evaluation and treatment and follow-up testing/counseling post exposure or injury occurrence as outlined in the employee health policy and Procedures, Infection Control Policy and Procedures, and guidelines for Exposure control Plan Policy and Procedures.         
29. Participates in the Nursing Administration Call schedule.  This includes answering calls and texts messages, providing guidance, working as staff when needed, providing callback, and doing so within the call schedule policy, procedure, and guidelines.
30. Co-chair the Nursing Peer Review Committee, following policies and procedures of the district as well as the Board of Nursing.
31. Attend and participate in nursing and nursing administration meetings, including in-services and training, at the discretion of the Chief Nursing Officer.  
32. Provide education, training, and educational assistance when necessary that falls under scope of practice. 
33. Other job duties as assigned and allowed by licensure.

Education and Experience

1. Minimum 5 years nursing experience.
2. Bachelor’s degree in nursing required.
3. Current RN license required.
4. BLS
5. ACLS or equivalent  
6. PALS/ENPC  
7. Certificate for infection control (may be obtained within 90 days of hire)
8. National Healthcare Network certification (may be obtained within 90 days of hire)
9. Preferred Certified credentials for professional in Healthcare Quality (CPHQ)
10.  Centers for Disease Control knowledge

Skill Requirements

1. Leadership
2. Organization
3. Detail oriented
4. Communication
5. Time management
6. Independent
7. Problem solving/ analysis.
8. Nursing knowledge
9. Computer skills

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

1.         Extended periods of sitting and standing

2.         Manual dexterity

3.         Repetitive motion

4.         Bending and Kneeling

5.         Walking

6.         Pushing and pulling

7.         Lifting > 50 pounds

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