Quality & Patient Safety Advisor (Per Diem)

Cape Cod Healthcare•Hyannis, MA

34d•Onsite

About The Position

This role is responsible for various aspects of quality improvement and patient safety within the hospital. Key responsibilities include data abstraction and analysis for regulatory reporting, process and systems improvement using methodologies like PDCA, and supporting continuous quality improvement culture. The position also involves program development, public and internal reporting, assisting with peer review activities, and ensuring compliance with various healthcare regulations and standards. Additionally, the role supports patient safety initiatives, regulatory compliance, and participates in root cause analyses and failure mode and effects analyses. The advisor will also be responsible for specific service line or program duties and providing excellent service to all stakeholders.

Requirements

RN license required
Baccalaureate Degree in Nursing required
Effective communication skills
Excellent presentation and facilitation skills
Demonstrated competence in quality data analysis and presentation
Minimum of 5 years of experience in Hospital with progressive experience in quality improvement
Minimum of 5 years of experience in Quality Database and/or system management

Nice To Haves

Master’s Degree preferred
CPHQ preferred or proven experience in quality/process improvement and regulatory compliance

Responsibilities

Data abstraction for applicable data measures with adherence to specifications manuals.
Monitoring data entry into MIDAS for reliability of Core Measure data elements.
Maintaining knowledge of changes in data definitions and variables for reporting data measures.
Ensuring data accuracy and meeting submission timelines for required entities.
Searching external databases and websites for data submission requirements and specifications.
Using data abstraction tools to produce meaningful analyses and correlation of data.
Collecting, aggregating, analyzing, and reviewing data for improvement opportunities.
Coordinating development and implementation of action plans for clinical/process issues using PDCA methodology.
Collaborating with staff to serve as a resource regarding core measures requirements and quality initiatives.
Utilizing national benchmarks and standards of care in developing action plans for QI/PI.
Supporting a hospital-wide culture for continuous quality improvement.
Facilitating and collaborating in designing new processes that develop/monitor quality indicators.
Establishing innovative processes to improve quality.
Preparing reports and improvement plans.
Consulting on quality monitors, including data collection, sample size, and analytical tools.
Supporting Performance Improvement/Patient Safety/Quality initiatives and taskforces.
Maintaining proficiency in MIDAS+, DataVision, and other assigned databases.
Collaborating with Quality/Safety Program leaders on implementing evidence-based initiatives and monitoring measures.
Partnering with Program leaders on program evaluation and identifying improvement opportunities.
Assessing clinical and non-clinical outcomes using established measurement systems.
Disseminating information to internal customers in a simple, understandable graphic format.
Assisting with peer review activities under the guidance of the CMO.
Organizing findings, actions, and recommendations for peer review and maintaining the MIDAS peer review database.
Providing trend analysis of physician-specific quality data for re-appointment and performance improvement.
Ensuring compliance of the Medical Staff with TJC Standards, DPH Conditions of Participation, OSHA regulations, and BoRM PCA semi-annual reporting.
Eliciting support for valid, reliable data reporting to regulatory agencies.
Remaining current with regulations/standards from CMS, BoRM, TJC, DPH.
Communicating regulatory changes to hospital committees, taskforces, and teams.
Coordinating activities with the Executive Director for successful accrediting, licensing, and certification surveys.
Coordinating completion of Semi-Annual Quality Analysis Reports for submission to the BoRM.
Participating in Root Cause Analyses (RCAs) and Failure Mode and Effect Analyses (FMEAs).
Facilitating process change based on RCA/FMEA findings and providing support for monitoring effectiveness.
Providing feedback to management on process improvement initiatives, dashboard data, and indicator screening trends.
Fulfilling specific service line/program responsibilities as assigned.
Consistently providing service excellence to all patients, family members, visitors, volunteers, and co-workers.