Summary: Fall River Health Services (FRHS) is a comprehensive healthcare system, which services Fall River County and the surrounding areas in the beautiful Black Hills of South Dakota . We are comprised of a 25-bed Critical Access Hospital, 24-hour Emergency Department, Seven Sisters Living Center (LTC), in-house Rural Health Clinic plus ancillary services. We provide for the physical, emotional, and spiritual needs of the individual, family, and significant others. We are committed to our patients, residents, employees and our community. We offer a comprehensive benefits package to all full time employees. Compensation is based upon your experience and qualifications. Full time employees are eligible for our comprehensive benefit package including medical ( $90/month premium for single person and $500 annual deductible ), vision, dental and much more!

Description: The Quality Assurance and Performance Improvement (QAPI) Coordinator develops, implements and manages the QAPI Plan and related programs by coordinating with organization workgroups to foster compliance with standards established by Fall River Health Services, the State of South Dakota and federal governing agencies. This position carries out specific projects as designated by Executive Leadership or related committees as requested.

• Manage the development, implementation and evaluation of the organization’s QAPI program, including ancillary, nursing, and medical staff departments, to identify trends, prioritize and recommend improvements, decrease duplication and ensure compliance with the standards established by FRHS, the State of South Dakota, Centers for Medicare & Medicaid Services (CMS) and other regulatory agencies.
• Develop, implement and oversee quality improvement to ensure delivery of the highest quality patient care using a multidisciplinary approach, optimal patient flow, provider productivity and continuity of care.
• Develop a conceptual framework for quality measurement and improvement activities organization-wide.
• Organize, compile and analyze data, observe and evaluate operations and consult with leadership, staff, residents, families, and other stakeholders to identify trends or areas of concern, establish priorities and recommend improvement opportunities.
• Lead development of QAPI projects, action plans and quality assurance policies and procedures in collaboration with department managers and related committees to attain organizational goals and meet accreditation standards.
• Review, interpret and communicate QAPI goals and objectives to ensure processes, products and patient/resident care services is improved.
• Organize and facilitate the QA Committee and its meetings by guiding discussion around performance measures, prioritizing and developing quality efforts and the progress of PI projects.
• Prepare the annual QAPI Plan and schedule for review, revision and approval annually.
• Prepare reports and actions plans as requested, including the annual QAPI Report.
• Review the monthly Quality Indicator reports to identify system deficiencies and work with department managers and medical staff to plan corrective action
• Ensure QAPI plan prioritizes objectives and activities based upon short term and long term strategic planning process.
• Conduct Root Cause Analysis for clinical adverse events and near miss events; develops action plans to reduce risk of recurrence; follows the progress of these action plans
• Guarantee delivery of optimal patient/resident care within available resources and consistent with the mission and goals of FRHS.
• Create processes and develop monitoring and evaluation tools to establish key indicators for performance improvement.
• Identify and manage potential barriers, or unintended consequences of change that might impact the success or overall performance of QAPI efforts.
• Monitor, evaluate and improve the quality and appropriateness of patient/resident care through routine data collection and analysis.
• Request or collects data to generate reports, which monitor and document implementation of corrective action, recommendation, evaluation and assesses the impact of instituted changes.
• Investigate incident reports, patient complaints, patient care issues and other issues and identify trends of care or system deficiencies.
• Perform comprehensive, concurrent, and retrospective quality assurance reviews and audits such as patient charts, psychotropic drug review, compliance, admission documentation, etc., and address any deficiencies related to direct and indirect quality care and activities.
• Report findings to appropriate departments such as utilization review, infection control, risk management and/or regulatory agencies.
• Collaborate and respond to survey findings in a proactive, positive and problem-solving manner developing quality assurance measures to improve services and customer satisfaction.
• Coordinate with department managers to ensure QAPI efforts are integrated into all operations and departments, including staff responsibilities and build needed skills in others to lead PIPs.
• Ensure employees understand patient-focused performance by providing feedback of measures and indicators of patient reception and reaction to services.
• Ensure facility policies and procedures are implemented and reviewed as necessary.
• Develop forms, manuals and documents, provide instructions on the program standards, coordinate and monitor the implementation of the standards of care.
• Enhance professional growth and development through participation in QAPI continuing education programs, trainings, research, in-service meetings and workshops; stay current on standards of practice; show responsibility for own professional practice and ongoing education and learning.
• Develop and deliver quality assurance and regulatory education, in-service programs and competencies to improve identified deficiency trends and promote an organizational culture of quality and leadership.
• Performs other duties as requested by Executive Leadership or Medical Staff.

• Requirements: Communicate the mission, ethics, and goals of FRHS.
• Comply with all FRHS policies and standards.
• Act with integrity, professionalism, and confidentiality.
• Maintain confidentiality of all protected health, financial, and legal information.
• Possess effective managerial, communication and leadership skills.
• Foster effective working relationships and build consensus.
• Function successfully in a team environment to achieve objectives.
• Plan, organize, prioritize, work independently, and meet deadlines.
• Strong organizational skills and attention to detail.
• Communicate effectively, both orally and in writing.
• Ability to develop, update and implement effective solutions and maintain accurate records.
• Conduct analysis and formulate conclusion(s) or determine appropriate course of action.
• Knowledgeable in data collection, data analysis methodology, and performance improvement methods needed to support and lead QAPI.
• Working knowledge of quality assurance standards and techniques of healthcare operations and services; knowledge of statistics and statistical data displays
• Demonstrated ability to develop curriculum for and provide in-service education.
• Excellent interpersonal, negotiation, and conflict resolution skills.
• Use judgment and make sound decisions.
• Maintain a professional, organized and clean working environment

Bachelor’s degree in nursing from an accredited college or university. Minimum three years of clinical nursing experience, medical/surgical preferred. This position must possess a current, unencumbered professional nurse’s license from the State of South Dakota. BLS Certification & Certification from Healthcare Quality Certification Board preferred.