Quality Standards Coordinator (FT) - LaVeta Surgical Center
Company: Surgical Care Affiliates
Location: Orange
Posted on: May 5, 2022
Job Description:
US-CA-Orange - US-CA-Irvine - US-CA-Orange - US-CA-Newport
Beach
# of Openings: 1
Category: Other
System ID: 20309
Group Name: TGS
Overview
Surgical Care Affiliates (SCA) is transforming specialty care in
our communities. We relentlessly create value by aligning
physicians, health plans and health systems around a common goal:
delivering exceptional care and healing to our patients and
communities we serve. We are driven to achieve the quadruple aim in
health care: high quality outcomes and a better experience for
patients and providers, all at a lower total cost of care. As a
national leader in surgical care, SCA's 10,000 teammates operate
more than 250 surgical facilities that serve nearly 1 million
patients per year. For more information on SCA, visit
www.scasurgery.com.
Why join SCA? Consider the following fantastic benefits...
- Positive work culture
- Career growth opportunities
- Comprehensive medical, vision and dental insurance - eligible
on Day 1 of employment
- Paid time off plus 8 paid holidays
- Maternity/paternity/adoption benefits
- Employer-paid life and short- and long-term disability
insurance
- Excellent 401(k) Plan
Accountabilities / Responsibilities
A. Maintain knowledge of:
- Clinical best practices
- Accreditation and regulatory standards
- Quality improvement processes
- SCA Quality Standards Manual
- SCA Governing Body (GB) and Medical Executive Committee (MEC)
Bylaws
- Center Medical Staff Rules & Regulations
- SCA policies and procedures
- Infection Control guidelines
- Nationally recognized patient safety goals (NPSG's) for
ASCs
- Environmental safety regulations and guidelines
- SCA Environment of Care (EOC) Manual
- SCA Medical Staff Services and Credentialing guidelines
- SCA Medical Staff Services and Credentialing Manual
- Center and regional education, orientation, and training
programs
- ASC center leadership responsibilities
- SCA Homepages: Clinical Resources, Quality Standards,
Environment of Care, Credentialing
B. Lead, facilitate, and advise the Center Quality Council and
internal performance improvement teams:
- Set the agenda and maintain meeting minutes
- Ensure reporting of all mandatory and center specific monthly
and quarterly reports for trends/areas for improvement to the
Quality Council and Medical Executive Committee/Governing Body a
minimum of quarterly:
- Medical Record Audit reports; Monthly or quarterly data
collection from ongoing systematic chart review to assess quality
of documentation.
- Infection Control reports
- Hospital Transfer/Complication reports
- Patient Safety; measurement of key measures of patient safety
and hazard analysis/process redesign (adverse events, root cause
analysis).
- Life safety (environment of care); Provide for a detailed
assessment and evaluation of the Environment of Care (EOC) and the
associated conditions, staff education and readiness and the
various processes. Framework for the EOC includes the management
processes and systems that affect safety, security, hazardous
materials, emergency preparedness, life safety, medical equipment,
and utilities management.
- Risk Management (incident reporting)
- Adverse Drug Reaction reports
- Cancellation logs
- Service Satisfaction reports (patients, staff and
physicians)
- Center specific quality indicator reports as appropriate
- PI reports; Collection, analysis and summary of performance
improvement data.
C. Provides strategic oversight of proactive and reactive patient
safety activities:
- Root cause analysis.
- Clinical practice guidelines
- Sentinel Event Alerts
- Identification and data collection of center specific quality
indicators based on high risk, problem prone procedures as
appropriate.
- Review and revision of the PI Plan on an annual basis and
preparation of the annual report of the PI program to the Medical
Executive Committee/Governing Body.
- Documentation of all Performance Improvement activities and
maintenance of records for a minimum of three years.
D. Provides strategic oversight of proactive and reactive patient
safety activities (continued):
- Coordination of the center policies/procedures and processes to
be in compliance with the current standards of applicable
regulatory and accrediting agencies, and mandatory SCA Corporate
policies.
- Working with the Administrator/designee to ensure currency of
all physician files, medical staff appointments and/or privileges
and compliance with credentialing policies and procedures.
Coordinating as appropriate the peer review process and aggregate
individual peer review data for presentation and review by the
Medical Executive Committee and Governing Body at
reappointment.
- Working with the Administrator/designee to ensure currency and
completeness of all human resource and education files for center
employees and contract personnel.
E. Maintain Center Survey readiness
- Assess center compliance with accreditation standards and
regulations in collaboration with leadership and staff.
- Identify areas of vulnerability and direct the development of
strategies to enhance compliance.
- Provide the overall direction necessary to ensure that clinical
services provided are evidence-based, in accordance with standards
established through state and federal regulations and applicable
accreditation standards, including the National Patient Safety
Goals.
F. Communicate Effectively Throughout All Levels of the
Organization
- Proactively educate and train the leadership and staff
regarding regulatory issues, new statutes/guidelines, and
safety/quality/performance improvement activities and their
respective responsibilities in carrying out the performance
improvement program.
- Maintain effective communication on current center activities
related to Safety/Quality/PI and Accreditation and seek
consultation as needed for support from the Regional Quality
Coordinator or assigned Group Director.
Qualifications
- Work in concert with the Regional Quality Coordinator to
implement the SCA strategic clinical-quality plan.
- Possess excellent written and oral communication skills.
- Knowledge of standards, survey methodology and related tools
and resources for regulatory and accreditation requirements
- Regularly accesses internal and external resources to maintain
professional knowledge base.
PI176297570
Keywords: Surgical Care Affiliates, Orange , Quality Standards Coordinator (FT) - LaVeta Surgical Center, Healthcare , Orange, California
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