Under the leadership of the Director of Quality and Safety plans, conducts, and supports activities involving quality assessment and improvement activities. Compiles, analyzes and evaluates data using investigative, statistical methods, benchmark data, or other comparative measures. Leads and participates on teams related to quality improvement activities. Supports and assists in the development, education and maintenance of the quality improvement program. Responsible for promoting and monitoring safe, high quality, cost effective care. Strives for superior performance by consistently providing a product or service to leadership and staff that is recognized as ultimately contributing to the patient and family experience. Recognizes and demonstrates understanding of patient and family centered care.
Responsible To: Director of Quality and Safety
Workers Supervised: None
Inter-Relationships: All Memorial Healthcare departments, the Medical Staff and various external agencies, co-workers, internal and external customers.
PRIMARY JOB RESPONSIBILITIES
- Performs chart abstraction for selected measures related to the CMS/Joint Commission Core Measures and others as assigned. Maintains abstraction accuracy of at least 90% as validated by internal and external audits.
- Performs concurrent review of key core measure processes to ensure timely compliance.
- Collects data for other selected hospital quality initiatives including but not limited to: Keystone initiatives, Midas, and Leapfrog.
- Collects data for measures related to Pay for Performance and Value Based Purchasing initiatives.
- Conducts chart review for other indicators such as medical, surgical, maternal or fetal complications, mortalities, readmissions, bariatric complications and as requested.
- Analyzes data for trends and improvement opportunities.
- Creates reports and presentations of data in appropriate formats for individual and audience presentations.
- Presents quality data at assigned medical staff department meetings, including recommendations for improvement and facilitation of group discussion.
- Supports the peer review and credentialing process by completing clinical pertinence reviews; completion of initial peer review screening; preparation of peer review documents and coordination of the medical staff peer review process.
- Creates and distributes reports to management and administration in a timely manner. This may include special reports for the Board PI and Medical Executive committees.
- Achieves targets for key metrics by providing physician/staff training, process redesign and improvement team facilitation.
- Acts as system administrator for assigned software programs.
- Performs chart reviews when requested to assist the Director and other leaders in identifying quality of care, high risk issues.
- Participates in various hospital committees and teams as assigned.
- Researches literature to support quality improvement and patient safety activities. Maintains current knowledge of quality initiatives and pending changes required from regulatory bodies or other external agencies.
- Works collaboratively with other departments to achieve quality improvement goals.
- Acts as a resource to MHC Departments for quality improvement issues.
- Prepares and presents educational information and/or tools related to quality as indicated.
- Ensures that the use and retention of quality improvement and peer review information meets established policies.
- Demonstrates knowledge of and supports hospital mission, vision, value statements, standards of behavior, policies, operating instructions, confidentiality statements, corporate compliance plan and the code of ethical behavior.
- Delivers consistently excellent customer service to patients, co-workers, volunteers and others. Specifically, listen and ask questions for understanding, always ask how else you can help, follow-up to ensure that an issue has been resolved.
- Act as a public relations ambassador for Memorial Healthcare at all times. Specifically, speak positively about the organization, manage up co-workers, managers and others.
- Has a working knowledge of Memorial Healthcare services; reports issues, problems and suggestions to the appropriate person in a timely manner.
- Enhances personal growth through participation in internal and external education programs.
- Performs other related duties as required or requested.
DEPARTMENTAL AND ADDITIONAL JOB RESPONSIBILITIES
1. Other duties as assigned
- Unencumbered license as a registered nurse in the state of Michigan
- CPHQ certification preferred.
- Bachelors degree in a related field preferred.
- Minimum of three years experience working in a healthcare setting required.
- Preferred: Two years experience in healthcare quality improvement, clinical documentation or case management; experience with data collection techniques; interpretation of accreditation and certification requirements and quality improvement practices and procedures; and prior experience with statistical methods.
- Must be proficient at working with computers including basic proficiency with Microsoft Office applications.
ESSENTIAL PHYSICAL ABILITIES/MOTOR SKILLS
These physical requirements are not exhaustive and additional job related physical requirements may be added on an as needed basis. Corrective devices may be used to meet physical requirements.
- Sedentary Work: Frequently required to stand, kneel and crouch. On a daily basis may be required to move about, sit, climb stairs and bend. Is frequently required to lift and carry up to 20 lbs. May be required to push/pull items up to 100 lbs.
- Vision: Requires the ability to perceive the nature of objects by the eye. Near acuity: Clarity of vision at 20 inches or less. Midrange Acuity: Clarity of vision at distances of more than 20 inches and less than 20 feet.
- Motor Coordination: While performing the duties of the job is required to regularly to use hands and/or fingers, handle or feel objects, tools or controls and reach with hands and arms. Must be able to travel independently throughout the hospital; access patients/families including areas confined by space and/or equipment.
- Speaking/Hearing: Ability to give and receive information through speaking and listening skills.
ESSENTIAL TECHNICAL ABILITIES
- Proficiency using modern office, computer and telephone equipment as used by Memorial Healthcare.
ESSENTIAL MENTAL ABILITIES
- Demonstrated experience in critical thinking, problem resolution, active listening.
- Demonstrated ability to read and interpret a variety of documents including, but not limited to policies, operating instructions, white papers, regulations, rules and laws.
- Ability to author reports containing technical information.
- Ability to evaluate medical records for compliance with standards of care.
- Ability to analyze data.
- Ability to solve practical problems and deal with a variety of variables in situations where only limited standardization exists.
- Ability to develop and present educational programs.
- Ability to adapt and maintain focus in fast paced, quickly changing or stressful situations.
ESSENTIAL SENSORY REQUIREMENTS
- Able to see for the purpose of reading information received in formats including but not limited to paper, computer, reports, bulletins, updates, manuals.
- Able to hear for work-related purposes.
- Ability to interact with co-workers, hospital staff, administration, patients, physicians, the public and all internal and external customers in a professional and effective, courteous and tactful manner, at all times, physically, verbally and in all written and electronic communication.
- Required to remain calm when adversity is encountered.
- Open, honest, and tactful communication skills.
- Ability to work as a team member in all activities.
- Positive, cooperative and motivated attitude.
- Demonstrated ability to interact with people at various levels in a courteous, tactful and professional manner.
- Ability to maintain a professional demeanor at all times, physically, verbally and in all written communication.
- Ability to facilitate group meetings and projects involving people of differing levels of education, experience and ages, including people experiencing highly emotional situations.
- Exceptional communication techniques-both verbal and written.
- Demonstrated skills in service recovery.