Quality & Patient Safety Advisor

Cape Cod Healthcare•Hyannis, MA

8h•Onsite

About The Position

This role is responsible for various aspects of quality improvement, patient safety, and regulatory compliance within a hospital setting. Key responsibilities include data abstraction and analysis for performance measures, process improvement initiatives using methodologies like PDCA, program development and evaluation, public and internal reporting, and supporting peer review activities. The position also involves ensuring compliance with regulations from agencies such as CMS, BoRM, TJC, and DPH, coordinating survey activities, participating in root cause analyses, and providing feedback on process improvement initiatives. The role requires a commitment to service excellence and collaboration across various departments and with external regulatory bodies.

Requirements

RN license required
Baccalaureate Degree in Nursing required
CPHQ preferred or proven experience in quality/process improvement and regulatory compliance
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 preferred
Minimum of 5 years of experience in Quality Database and/or system management preferred

Nice To Haves

Master’s Degree preferred
CPHQ preferred

Responsibilities

Data abstraction of all applicable data measures with strict adherence to specifications manuals.
Monitoring data entry into MIDAS for data element reliability.
Maintaining current knowledge of changes in data definitions and variables for reporting.
Ensuring data accuracy and meeting submission timelines for required entities.
Searching external databases and websites to stay current on data submission requirements.
Using data abstraction tools to produce meaningful analyses and correlation of data.
Collecting, aggregating, analyzing, and reviewing data for improvement opportunities.
Coordinating the development and implementation of action plans for clinical/process issues using PDCA methodology.
Collaborating with clinical educators, coders, and other staff as a resource for core measures 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 the design of new processes to 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 the Medical Staff and Department Chiefs with peer review activities under the guidance of the CMO.
Organizing findings, actions, and recommendations for peer review and overseeing 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, and DPH.
Maintaining current knowledge of all Regulatory changes/Updates and communicating them to committees, taskforces, and teams.
Coordinating activities with the Executive Director for successful accrediting, licensing, and certification survey activities.
Collaborating with the Quality team and service line leaders in coordinating Semi-Annual Quality Analysis Reports for BoRM submission.
Participating in Root Cause Analyses (RCAs) and Failure Mode and Effect Analyses (FMEAs).
Facilitating process change based on RCA and FMEA findings.
Providing support to staff for monitoring and summarizing the effectiveness of process changes.
Providing feedback to management on process improvement initiatives, dashboard data, and indicator screening trends.
Performing other duties as assigned specific to service line/program responsibilities.
Consistently providing service excellence to all patients, family members, visitors, volunteers, and co-workers.