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RN, Registered Nurse- Rehab- Clinical Educator/ Performance Improvement Quality Coordinator

Christus Health

This is a Contract position in Texarkana, TX posted May 28, 2021.



  • 1.Maintain consistency with Administrative and Departmental policies with appropriate behavior, dress, attitude, attendance, confidentiality, professionalism, and reliability.
  • 2.Assures areas of responsibility are in compliance with regulatory agencies including education of all appropriate parties and seeks Process Improvement as evidenced by:
  • a.TJC
  • b.Improved policies, procedures and practices
  • c.Comparison of department or area outcomes to other CHRISTUS facilities
  • d.CARF Clinical Standards
  • 3.Takes initiative and identifies opportunities to deal with issues including customer complaints and associate related issues including staffing, retention, recruitment, turnover, communication, performance management, etc. as evidenced by:
  • a.Associate, Patient, and Physician Satisfaction Surveys
  • b.Process Improvement activities
  • c.Provide examples of initiatives taken to better meet customer needs and/or organizational goals
  • 4.Initiates and oversees the development of a comprehensive quality/performance improvement program inclusive of the analysis and trending of data related to organizational initiatives.
  • 5.Provides strategic oversite for patient safety and quality (PI) committees/teams with accountability for distribution of organizational communication vertically and horizontally within CSMRH.
  • 6.Provides overall direction necessary to ensure that clinical services are provided in accordance with standards established through state and federal regulations and TJC & CARF accreditation standards, including the National Patient Safety Goals and that they are evidenced-based.
  • 7.Coordinates Quality Initiatives with managed sites. Acts as a resource for PI initiatives in the managed sites.
  • 8.Monthly quality data to Director, Quality Outcomes (CSMHS) including patient days, CAUTI, falls, falls prevalence, falls with harm, patient satisfaction percentile and percent very good.
  • 9.Monthly chart audits for DVTs, transfers to acute, hand hygiene, two patient identifiers, critical lab and radiology, invasive procedures, nursing deficiencies, and transfusions.
  • 10.Entry into Risk Management software and investigation of patient complaints, phone calls to patients and families, and resolution letter within 7 days for both inpatient and all rehab outpatient departments. Graphs for patient complaints.
  • 11.Lead quarterly PI meeting including accumulating and presenting the following data: agenda, CARE Tool indicators, respiratory report, blood utilization report, tissue donation, patient perception of safety report, patient satisfaction with pain and overall report, pressure ulcers, and graphing all medication errors, monthly transfers to acute and readmission within 30 days for the quarter.
  • 12.Provide data for MEC quarterly, which includes the transfer to acute data from chart audits (about 20 charts per quarter), re-admissions from home report (usually around 15 chart audits), physician patient satisfaction report and PI Committee Board of Directors report.
  • 13.Lead and gather data to present to the quarterly physician peer review (OPPE) meeting including transfers to acute compared to nation and region from UDS, mortality review, physician patient complaints, timeliness of history and physicals, and prophylaxis for DVT report.
  • 14.Physician peer review data for all physicians on staff at rehab. Done twice a year, January and July. (A Joint Commission requirement).
  • 15.Identify and complete a Failure Mode Effect Analysis (FMEA) (Joint Commission requirement).
  • 16.Follow through with all Joint Commission Sentinel Even Alerts.
  • 17. Responsible for coordination of orientation and other continuing education programs; represents CHRISTUS St. Michael and supports planning of community activities.
  • 18. Performs all other duties assigned


  • Graduate of an accredited Registered Nursing program, Bachelor Degree preferred
  • Excellent customer service, negotiation and communication skills
  • Minimum of 3 years clinical patient care experience in a relevant setting
  • Minimum of 1 years of healthcare management experience
  • RN Licensure in state(s) of employment

  • Work Type: 
  • Full Time

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