Clinical Quality Specialist

Nashville General Hospital•Nashville, TN

2d•Onsite

About The Position

The Clinical Quality Specialist plays a crucial role in developing and maintaining current knowledge of CMS and State quality measure requirements. This position serves as a resource for various CMS quality programs, including IQR, OQR, PI, VBP, RRP, HACP, and CMS quality and patient experience star ratings. The specialist is responsible for downloading and interpreting CMS hospital-specific reports, conducting performance improvement initiatives, and evaluating the submission of Electronic Clinical Quality Measures (eCQM) and compliance with CMS structural measures. Additionally, the role involves designing and delivering education to medical and clinical staff on effective documentation related to quality measures and serving as a liaison for the Quality Improvement Organization (QIO). The specialist also chairs the Sepsis Committee, performs sepsis chart abstraction and analysis, and develops evidence-based sepsis care protocols. Furthermore, this role requires maintaining knowledge of Leapfrog Hospital Survey requirements, collaborating on survey completion, coordinating Leapfrog CPOE testing, analyzing Leapfrog safety data, and developing performance improvement plans to enhance the hospital's safety grade. The position also involves assisting with survey readiness, leading performance improvement teams, conducting project-based chart reviews, and presenting reports to the hospital Quality Committee.

Requirements

Completion of an accredited Registered Nursing program.
Licensed to work as a Registered Nurse in the State of Tennessee.
3+ years of data abstraction, informatics, or EMR documentation analysis.
5+ years of clinical nursing experience.
Working knowledge of basic business software such as Excel, PowerPoint, and Word.
Must obtain CPHQ or CPSS certification within 18 months of hire and remain active throughout employment.

Nice To Haves

Bachelor of Science in Nursing (BSN) preferred.
Experience in lieu of degree may be considered.
Knowledge of performance improvement methodologies preferred.

Responsibilities

Develops and maintains current knowledge of CMS and State quality measure requirements, including data interpretation and application.
Serves as a resource for CMS quality programs (IQR, OQR, PI, VBP, RRP, HACP, CMS quality and patient experience star rating).
As HQR system administrator, downloads and saves CMS hospital-specific reports, assists with interpretation, analysis, and conducts related quality performance improvement.
Reviews medical record documentation to evaluate compliance with established quality measures criteria; provides analysis/drill down and recommends areas for improvement; leads performance improvement initiatives.
Evaluates, validates, and ensures submission of Electronic Clinical Quality Measure (eCQM) in accordance with CMS requirements.
Evaluates compliance with CMS structural measures and implements plans for ongoing compliance.
Assists with CMS, State, and Joint Commission (ORYX) data submission as needed.
Ensures complete and accurate data is collected and maintained for CMS quality measures, including abstracted quality measures.
Designs and delivers education to medical and clinical staff regarding effective documentation in the medical record related to quality measures; reinforces interpretation of quality measure criteria.
Serves as the Quality Improvement Organization (QIO) liaison as needed.
Serves as Chair of the Sepsis Committee, prepares agenda and meeting materials, facilitates meetings, and manages follow-up items.
Performs sepsis chart abstraction, clinical data compilation, and analysis to identify trends and share reports.
Develops evidence-based care sepsis protocols, educates clinical staff, tracks patient outcomes, and ensures compliance with CMS sepsis quality measure (SEP-1).
Maintains working knowledge of Leapfrog Hospital Survey requirements and Leapfrog Hospital Safety Grade process and outcome measures.
Works collaboratively to complete the Leapfrog Survey, ensures Leapfrog requirements are met, and maintains required evidence documents.
Works closely with Informatics/IT to coordinate the Leapfrog CPOE test, identifies and prepares internal teams for testing, and develops and implements plans to optimize test scores.
Analyzes Leapfrog safety data to identify trends, gaps, and actionable improvement strategies; creates summary reports for stakeholders and leaders.
Translates analysis of Leapfrog safety data findings into measurable performance improvement plans.
Assists with survey readiness and survey management activities.
Leads and/or assists with multidisciplinary performance improvement teams using established problem-solving methodologies.
Performs project-based chart review and staff education in support of performance improvement initiatives.
Assists with agenda planning for the hospital Quality Committee and presents reports as assigned.
Effectively manages assigned projects with a level of independence and a problem resolution approach.
Actively participates as the department representative on designated multidisciplinary teams and Committees.
Supports clinical operations and clinical initiatives as assigned.
Attends required hospital-wide orientations, meetings, and in-services.
Maintains professional growth and development through seminars, workshops, and professional affiliations.
Performs other duties as assigned to include coverage of essential Department functions and services.