Quality Improvement Analyst, RN

Wabash General Hospital•Mt Carmel, IL

1d•Onsite

About The Position

The Quality Improvement Analyst RN is responsible for monitoring, analyzing, and trending hospital quality performance metrics, including electronic clinical quality measures (eCQMs), CMS Care Compare data, internal quality improvement indicators, and specialty program dashboards. This role supports regulatory and specialty reporting platforms such as AAOS registries, including the American Joint Replacement Registry (AJRR) and ASR reporting, as well as CMS, Leapfrog, and Joint Commission ORYX requirements. The analyst ensures data integrity and reporting accuracy by validating measure specifications, documentation requirements, abstraction logic, and submission processes across all regulatory and registry programs. Performance is evaluated against national and state benchmarks and programâ€‘specific expectations, with gaps and opportunities for improvement identified and prioritized. The analyst prepares dashboards, scorecards, and performance reports for leadership, quality committees, and interdisciplinary teams. In collaboration with clinical departments, providers, nursing, pharmacy, and hospital leadership, the analyst facilitates root cause analysis of underperformance and supports the development and implementation of corrective action plans. This role guides and supports performance improvement methodologies, including Planâ€‘Doâ€‘Studyâ€‘Act (PDSA) cycles, workflow redesign, and documentation improvement initiatives, with a focus on sustaining measurable improvements. Additional responsibilities include tracking performance over time, monitoring sustained gains, ensuring ongoing compliance with Leapfrog and ORYX measures, and escalating barriers to leadership as needed. The coordinator supports program readiness and regulatory reporting for CMS Inpatient Quality Reporting (IQR), MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, and specialty registries, including participation in audits, abstraction validation, and data review activities. The role also includes monitoring updates to measure specifications and evolving regulatory requirements and translating changes into operational guidance. This position plays a key role in identifying and prioritizing quality improvement opportunities, researching and evaluating required changes, and leading implementation efforts in partnership with clinical and operational teams. By analyzing workflows, performance data, and outcomes, the analyst supports the implementation, monitoring, and sustainment of quality improvements across the organization.

Requirements

Registered Nurse (RN) license
Experience in quality improvement
Knowledge of hospital quality performance metrics (eCQMs, CMS Care Compare data, internal quality indicators)
Familiarity with regulatory and specialty reporting platforms (AAOS registries, CMS, Leapfrog, Joint Commission ORYX)
Data integrity and reporting accuracy validation skills
Ability to analyze performance against benchmarks and identify improvement opportunities
Experience preparing dashboards, scorecards, and performance reports
Skills in root cause analysis and corrective action plan development/implementation
Knowledge of performance improvement methodologies (PDSA cycles, workflow redesign)
Experience tracking performance over time and monitoring sustained gains
Familiarity with CMS Inpatient Quality Reporting (IQR), MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, and specialty registries
Experience with audits, abstraction validation, and data review
Ability to monitor and translate updates to measure specifications and regulatory requirements into operational guidance
Strong analytical skills
Ability to lead implementation efforts
Collaboration and communication skills

Responsibilities

Monitoring, analyzing, and trending hospital quality performance metrics, including eCQMs, CMS Care Compare data, internal quality improvement indicators, and specialty program dashboards.
Supporting regulatory and specialty reporting platforms such as AAOS registries (AJRR, ASR), CMS, Leapfrog, and Joint Commission ORYX requirements.
Ensuring data integrity and reporting accuracy by validating measure specifications, documentation requirements, abstraction logic, and submission processes.
Identifying and prioritizing gaps and opportunities for improvement based on performance evaluation against national and state benchmarks.
Preparing dashboards, scorecards, and performance reports for leadership, quality committees, and interdisciplinary teams.
Facilitating root cause analysis of underperformance and supporting the development and implementation of corrective action plans in collaboration with clinical departments, providers, nursing, pharmacy, and hospital leadership.
Guiding and supporting performance improvement methodologies (PDSA cycles, workflow redesign, documentation improvement initiatives) with a focus on sustaining measurable improvements.
Tracking performance over time and monitoring sustained gains.
Ensuring ongoing compliance with Leapfrog and ORYX measures.
Escalating barriers to leadership as needed.
Supporting program readiness and regulatory reporting for CMS Inpatient Quality Reporting (IQR), MBQIP, Joint Commission ORYX, Leapfrog Hospital Survey, and specialty registries.
Participating in audits, abstraction validation, and data review activities.
Monitoring updates to measure specifications and evolving regulatory requirements and translating changes into operational guidance.
Identifying and prioritizing quality improvement opportunities.
Researching and evaluating required changes.
Leading implementation efforts in partnership with clinical and operational teams.
Analyzing workflows, performance data, and outcomes to support the implementation, monitoring, and sustainment of quality improvements.