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Clinical Quality Improvement Coordinator
4 months ago
The Clinical Quality Improvement Coordinator is responsible for development, implementation, monitoring and analysis of appropriate methods of quality assessment/assurance and quality improvement projects and activities as part of the Quality Management Program. This position reports to the Quality Manager.
Essential Functions and Responsibilities- Provides concurrent chart reviews on the hospital units indicating to frontline staff, Physicians and the Unit Manager of quality measures out of compliance to ensure timely follow up using both written and verbal communication along with sending weekly reports to the Unit Manager, Quality Manager and AVP of Quality and Clinical Excellence
- Develops concurrent chart review audit forms and weekly report form to provide feedback to frontline staff, Physicians and the Unit Managers; investigates and analyzes deviations (both positive and negative) then communicates trends and opportunities in written reports to Unit Managers, Physicians and appropriate healthcare leaders
- Provides education to specific groups for performance improvement such as at unit staff meetings, flyers with quality measure information and tips, Resident Training and skills fair; posts quality measure data on learning boards in hospital staff break rooms
- Acts as a change agent with frontline staff, Physicians and Unit Managers with focus on documentation improvements and effectiveness
- Responsible for development, implementation, monitoring and analysis of appropriate methods of quality assessment/assurance and quality improvement projects and activities as part of the Quality Management Program
- Interacts with all internal and external customers in a caring and respectful manner in accordance with our Core Values philosophy
- Provides ongoing support to the quality of care provided to our patients and families
- Manages projects and activities for patient safety and quality
- Participates in service excellence, accreditation activities and initiatives
- Provides input and recommendations to the quality management team for quality and safety projects and initiatives
- Manages various data projects, reports and dashboards pertaining to key performance indicators
- Ensures that project plans include measurements of program and individual outcomes, productivity measures, and are in compliance with all applicable legislative and accrediting organizations
- Works with direct supervisor to coordinate initiatives aimed at meeting or exceeding clinical performance measure targets (for example: CMS Core Measures)
- Leads clinical quality improvement projects
- Coordinates quality improvement and risk management activities
- Leads teams through standardized quality improvement methodologies and quality improvement cycles
- Conducts chart abstractions from medical records (example: CMS' Core Measures)
- Identifies streamlining and process improvement opportunities in the data collection process which includes identifying successes, trends, and contributing factors then develops action plans, methods to control, target dates and conclusions
- Completes targeted audits as requested and as deemed necessary by leadership
- Collects, aggregates, analyzes and inputs data related to blood products, Core Measures, Specialty Physician Incentive Measures, Conscious Sedation, Mortality, Falls, Critical Lab Values and other databases or monitoring activities as assigned
- Supports risk management and medical staff services
- Bachelor's degree in health care or business related field required; OR four years of experience working in quality, data analysis, managed care and/or utilization tracking
- Active RN license in the state of Indiana required
- Clinical Nurse Specialist Advanced Practice Certification preferred
- One year of managing cross-functional projects required
- Improvement plan development experience preferred
- Lean or Six Sigma training preferred; or experience with Six Sigma or other quality improvement methodology
- Two years of recent Quality Management experience preferred
- Experience with Medicaid Managed Care preferred
- CPHQ certification preferred or willingness to become CPHQ certified over time