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Quality Assurance Coordinator

Company: Beaumont Hospitals
Location: Royal Oak
Posted on: November 22, 2021

Job Description:

GENERAL SUMMARY: Responsible for regulatory compliance and quality standards of the program. Ensures compliance with all applicable requirements mandated by federal, state, and accreditation agencies. Performs risk assessments, data analysis, and audits of effectiveness of the quality system, compliance processes, and controls. Plans, coordinates, and implements the process improvement programs of Beaumont Health that foster a high reliability organization, optimal operational, clinical, customer satisfaction, and financial performance. Leads and assist departments in developing best-practice processes to assure the highest quality results. Establishes and conducts training programs, direct internal and external audits, and other quality management functions. Supports industry best practices and corporate objectives. ESSENTIAL DUTIES: 1. Designs, develops, and maintains quality systems and written procedures to address general compliance mandated by regulatory/accrediting agencies. 2. Perform audits, supplier qualification reviews, risk assessments, and records reviews on the effectiveness of quality and compliance processes and controls. 3. Coordinates and manages inspection process. Ensures compliance with regulatory requirements and accreditation standards to include but not limited to FDA, FACT, CAP, TJC, CMS, OSHA, and ISO. Advises management staff on the status of compliance with current regulations, directives, and inspection findings. 4. Coordinates and maintains Accreditation Standards: annual survey and renewal, survey distribution, deficiency response follow-up, the routing, documented review and retrieval of survey documents, and survey archiving. 5. Maintains applicable establishment accreditation, product licenses and regulatory files. 6. Performs analysis and makes recommendations changes to achieve program strategic goals. Work includes developing and implementing performance measures/quality indicators, data collection and statistical analysis for continuous improvement. 7. Monitors, reviews department processes; recommends and assists with facilitating quality improvement efforts, and, as needed, provides direction to guide the QA team and its quality systems, reviews final data reports, maintains documentation and follow-up to system deficiencies. Supports industry best practices, corporate objectives. 8. Coordinates and directs variance reporting activities to include: the distribution and retrieval of incoming and outgoing variance report documents, applicable department investigation, review and follow-up, on-line documentation of variances into the hospital Quality System database and where applicable event/deviation/adverse reaction reporting with external agencies including but not limited to CAR-T Manufacturers, regulatory, and accrediting agencies. 9. Coordinates the reporting of infectious organisms and other notifiable test results, as is required by local and state authorities, as applicable. 10. Actively involved in decision making and assisting with the establishment of policies and protocols. 11. May include data collection and maintenance of database. 12. Maintains proficiency and knowledge regarding ongoing changes, regulatory requirements, accreditation standards, and industry practices. 13. Maintains position related competencies and requirements. This document represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described. STANDARD REQUIREMENTS: 1. Supports the Mission, Value and Vision of Beaumont Health (BH). Demonstrates personal commitment through active involvement in the performance improvement process. 2. Exhibits excellent customer service skills and behaviors toward internal and external customers and co-workers. Promotes positive public relations with patients/residents, family members, guests, and others. 3. Supports and adheres to all Beaumont Health's customer service, service excellence, and performance standards. Supports and participates with all required compliance standards that may be department specific and/or identified by the organizations including in-service training, acceptable attendance, uniform and dress code. 4. Adheres to HIPAA requirements and maintains confidentiality of all data, including patient/resident, employee and operations information. 5. Supports and participates in a collaborative team-oriented environment - cooperates and works together with all co-workers, plans and completes job duties, uses appropriate communications in sensitive and emotional situations and follows up as appropriate regarding reported complaints, problems and concerns. 6. Supports, cooperates with and demonstrates safe work practices and attitudes, follows safety rules - including universal precautions - reports and prevents/corrects unsafe conditions and behaviors, and participates in organizational and departmental safety programs. 7. Completes all required compliance standards that may be department specific and/or identified by the organization. 8. Maintains current licensure, registration and/or certification, as applicable, at all times. STANDARD QUALIFICATIONS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties. A. Education / Training: Bachelor of science degree required. B. Work Experience: Minimum of 3 years in healthcare. Preferred experience with QA, Accreditation, and Regulatory Compliance. C. Certification, Licensure, Registration: Preferred: MT (ASCP), HTL, ASQ SSBB D. Other Qualifications: * A demonstrated excellence in interpersonal, verbal and written communication skills. * Working knowledge of Microsoft Office skills including word and Excel. * Statistical analysis experience preferred. * Ability to coordinate complex activities and work independently and as an effective member of the team * Ability to deliver effective presentations, teach, mentor, and effectively implement the "Plan, do, Check, Act" process. * Ability to prioritize responsibility, meet deadlines, and be flexible / adjust to change.

Keywords: Beaumont Hospitals, Royal Oak , Quality Assurance Coordinator, Other , Royal Oak, Michigan

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