Assists in measuring and analyzing clinical data to improve quality of patient care and cost-efficiency for the organization.
Requirements
Bachelor of Science in Nursing (BSN) or Master’s degree in Nursing
California Registered Nurse (RN) licensure
Three (3) years of RN, performance/quality improvement or healthcare analytics experience
Ability to abstract cases for presentation in committees and Root Cause Analysis meetings
Ability to adapt quickly to changing priorities and unexpected situations
Ability to apply screening criteria against the medical record
Ability to collect, analyze and disseminate data, including financial and statistical data
Ability to effectively communicate in a positive and professional manner
Ability to set goals and work independently and efficiently with minimal supervision
Ability to speak in front of groups with confidence and clarity
Ability to take accurate and comprehensive committee minutes and draft committee correspondence
Computer skills, to include data entry, spreadsheets, graphics, information systems
General working knowledge of regulatory standards including Joint Commission, Medicare (CMS) and Title 22 (state) requirements
Knowledge of performance improvement tools, and the ability to use them effectively
Written and verbal communication skills
Nice To Haves
Healthcare Quality Certification (CPHQ), Certified Professional in Patient Safety (CPPS) or other relevant certification
Experience working with clinical outcomes data systems and resource management
Responsibilities
Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
Participates in regulatory body surveys (e.g. Joint Commission, California Department of Public Health) and assist in monitoring of action items as requested.
Assists with TJC Periodic Performance Review (PPR) and disease specific certification process by providing structure and process to organization stakeholders.
Assures accreditation survey reference-documentation binders are updated routinely.
Coordinates and schedules facility-wide TJC tracers, including distribution of results and requests for follow-up from various department.
Facilitates meetings/projects that support TJC, CDPH, CMS and other regulatory readiness (e.g. Sentinel Event Alert Gap Analysis/ Action Plan Teams, Proactive Team Assessments and Mock Survey Response Teams).
Researches current findings of best practice and provide this information to appropriate clinical performance improvement teams.
Acts as facilitator and minute keeper for PI teams as required.
Analyzes, disseminates, and presents hospital outcomes data using statistical tools (i.e. process control charts, descriptive statistics, etc.) in an appropriate manner, as requested.
Prepares reports illustrating quality measures, data and recommendations.
Implements tracking systems to measure the effectiveness of interventions.
Communicates with team members and participates in appropriate committees to report process-outcome information.
Provides education to customers regarding process-outcomes data, specific data elements and other issues as identified.
Supports Root Cause Analysis process as requested.
Documents conclusions, recommendations and actions of Root Cause Analysis Meetings and distribute to appropriate individuals for follow up as requested.
Assists with projects supporting the Quality Department (e.g. identification of clinical financial-process measures to improve clinical outcomes and cost-efficiency, cost analysis based on research and financial data).
Assists with Quality Council agenda, minutes, follow-up, and related reports for medical committees and Board of Director, as directed.
Acts as a quality improvement leader and is a resource to the hospital, and the medical staff regarding TJC, CMS, and Title 22 standards.
May support Medical Staff Quality Improvement/Peer Review Committees as appropriate.
May be responsible for core measure abstraction.
May assume coordinator responsibilities for the Sepsis core measure.
May act as an assistant to the Infection Preventionists.