The Quality Department Nurse supports and assists the Quality
Department in multiple aspects of quality-driven and regulatory
initiatives, data tracking and trend reports related to quality and
regulatory initiatives. Participates in staff education, employee
health and infection prevention and control activities.
+ Assists in facilitating data collection, tracking and trending
of clinical quality improvement activities in the simplest, most
+ Uses discretion to report matters of significance to the Chief
Medical Officer/Chief Quality Officer (CMO/CQO) and Associate
Director of Nursing and Quality (ADNQ) or other relevant
+ Schedule, conduct, track emergency code drills and training to
assist in the improvement of the emergency response team and
facility emergency systems (e.g., response protocols, emergency
drills, resource management and emergency communication)
+ Collaborate in evaluation of emergency drills and events
+ Assist with tracking and scheduling of outside inspections
related to quality and safety, i.e. fire and medical equipment.
+ Assist in creating, maintaining and updating manuals and
documents necessary for Joint Commission survey and/or other
accreditations or recognitions, including tracking of compliance
with all federal, state, and local requirements and various funding
agencies related to Environment of Care and Safety
+ Participates in management of the Employee Health program for
+ Demonstrates excellent customer service skills required for
extensive interface with providers, staff and clients, including
persons from diverse cultures and medically underserved
+ Attends required meetings and participates in system wide
councils or committees as requested, offers support and suggestions
for ongoing Q/QA activities.
+ Maintain working knowledge of requirements of The Joint
Commission (TJC), Texas Health Steps (THS), Department of State and
Human Services (DSHS)-related programs, Health Resources and
Services Administration (HRSA) and Bureau of Primary Health Care
(BPHC), etc., as related to job duties.
+ Participates in performance improvement activities, as
assigned, including clinical and environment of care (EOC) tracer
activities on an assigned basis.
+ Works well under, and meets, deadlines, ensuring timely flow
of information to, from and within the Quality Department.
+ All other duties as assigned.
+ Maintain competency and education related to vaccines, vaccine
storage and handling, administration and immunization
+ Works closely with Clinic Site Managers/Vaccine Coordinators
on all aspects of vaccine management.
+ Ensures compliance with all regulations related to vaccine
+ Provides vaccine and vaccine audit related education to staff
in person and via the learning management system (LMS).
+ Communicate and work with the CMO/CQO and ADNQ to implement or
provide immunization support deemed necessary.
+ Maintain a contact relationship with the Department of State
Health Services (DSHS) Regional Vaccine Coordinators for associated
+ Collaborates with the Director of Pharmacy, CMO/CQO, and ADNQ
to assess need and order annual flu vaccine.
+ Assists with completion of new and annual site applications
for Texas Vaccines for Children (TVFC) and Adult Safety Net (ASN)
programs, hereafter noted as State Vaccines.
+ Prepares, completes, maintains, and submits reports on State
and Private Vaccines.
+ Ensures that the clinic sites and NextGen IT staff have the
current VIS for each vaccine.
+ Attend State/Regional trainings to support the vaccine
+ Achieves and maintains competence in NextGen in order to
accurately abstract data for audits.
+ Maintains competence in NextGen medical records functions and
compliance with HIPAA rules and regulations.
+ In coordination with the Custodian of Records, works with
third party payers on patient medical record audits.
+ Maintains a working knowledge of documentation requirements
for various programs including Texas Health Steps (THS) and other
+ Performs documentation audits as required.
+ Prepares, completes, maintains, and submits reports on audit
activities as requested.
+ Assist staff and management in the determination of reliable,
valid, and measurable quality and patient safety indicators as
related to IPIC.
+ Assists in monitoring data and trends related to IPIC.
+ Assists in ensuring cost effective, technology-based access to
current information on IPIC and epidemiology including appropriate
data collection and action plans.
+ Assists in the ongoing compliance with regulatory and
accreditation requirements and best practices related to
communicable disease management.
+ Collaborate with appropriate state and local health
departments for reporting, surveillance, and follow-up of
communicable diseases and related conditions.
+ Performs appropriate follow-up of communicable disease
exposures in the clinical setting.
+ Monitors blood borne pathogen and infection control practices
and prepare appropriate reports.
+ Provide staff training and education as related to IPIC.
+ Assists in new hire and annual health screens and
+ Assists in coordinating the annual influenza immunization
+ Assists in the completion of all required annual and periodic
REQUIRED EXPERIENCE, EDUCATION, AND LICENSE:
+ Graduate of an accredited nursing school
+ Valid Texas LVN or RN license
+ BLS (CPR & AED) certification issued by the American Heart
+ Minimum of two (2) years of experience in a clinical setting
or an equivalent analytical position consistent with the needs of
PREFERRED EXPERIENCE, EDUCATION, AND LICENSE:
+ Proficiency with EMR system
+ Proficiency with MS Office Suite (Word, Excel, and
+ Bilingual English/Spanish language skills
+ CPHQ certified or the ability to obtain CPHQ certification
within 6 months of hire
External Company Name: Lone Star Circle of Care
External Company URL: http://www.lscctx.org/
Street: 2423 Williams Drive