Clinical Quality Improvement Coordinator

University of Maryland Medical System•Largo, MD

2d•$45 - $67

About The Position

Located in Largo in the heart of Prince George’s County, our new state-of-the-art regional medical center (UM Capital Region Medical Center) will provide improved access to primary and ambulatory care services, and serve as a tertiary care center for critically ill patients. In addition, our new space will allow us to expand our offerings as a community partner to help improve the health status of Prince George’s County residents. Required : Current Maryland license in good standing as Registered Nurse. P OSITION SUMMARY Conducts quality assurance compliance audits, reviews policies and procedures. Responsible for training new employees or existing employees and implementing changes in work behavior or tactics. QI Coordinator monitors and manages projects that directly impact the facility’s performance while capturing metrics, statistics or data from personnel or work outcome.

Requirements

Current Maryland license in good standing as Registered Nurse.
Bachelors of Science in Nursing.
Graduation from an accredited school of nursing.
5 years clinical experience
At least 2 years (combined) QA, QI, RM, UR, CM experience

Nice To Haves

Masters preferred

Responsibilities

Supports systems designed to promote hospital-wide performance improvement. Via Review of Medical Record for issues related to quality and performance
Performs concurrent and retrospective review of core measure patients and/or quality indicators in compliance with National Hospital Inpatient Quality Measures, Vermont Oxford Network and regulatory agencies such as Joint Commission, CMS, HQID project, MIEMSS, DHMH, HSCRC, etc.
Knowledgeable about core measures, Vermont Oxford Network Data, etc., informing director of changes in protocol/data requirements and implications for clinical practice
Participates in the education of medical staff, employees, leadership and Board on quality and performance indicators selected by the organization as well as the requirements and implications of these measures for clinical practice
Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis and other studies) requested by medical staff, hospital departments and committees
Flags and documents variances for selected indicators and variables for focused studies and implements indicators for medical staff and peer review including OPPE and FPPE as required by TJC
Participates in data extraction for submission of required data electronically to Vermont Oxford, MIEMSS, NAS Collaborative and DHMH. Facilitates the organization’s responses in order to meet established time frames for submission
Collects, interprets and reports data at specified intervals with accuracy and completeness
Demonstrates proficiency in abstraction and interpretation of data reports
Identifies and interprets objective and subjective data found in the medical records
Compares the identified data to established criteria to determine appropriateness of care
Abstracts and reports PI information in appropriate format to detect patterns and/or problems in the delivery of care
Identifies potential areas for change and improvement of the study design and data collection and makes recommendations
Develops new ongoing quality projects and evaluates the appropriateness of indicators and criteria for quality monitoring
Maintains current knowledge of PI strategies, principles, methodologies, techniques and data analysis.
Maintains current knowledge of TJC, CMS, national quality indicator guidelines, Magnet, NANN, AWHONN, NAN and NDNQI and assesses compliance for assigned areas.
Works with Leaders, Chiefs, Vice Chiefs and different service lines as well as facility Committee Chairs to organize and accomplish goals of required committee meetings, collaboratives and teams
Executes effective improvement projects through multidisciplinary team collaboration
Active participant in service line committee/council meetings and proactively provides reports and information as required by the committee or team and meets 90% attendance
Assures that issues are communicated to appropriate committees or individuals and that issues have timely resolution
Maintains peer review information in strict confidentiality and assures entry into database and PI file
Coordinates assigned meetings, assisting with agenda and providing all data metrics from various committees.
Evaluates referrals to the Quality Department. Refers issues to appropriate department Risk Management, Infection Control and Pharmacy. Follow up as needed.
Maintains confidentiality of QA material
Participates in CQI teams to improve organizational performance such as FMEA, RCA.