Clinical Quality Improvement Coordinator

4 weeks ago

Indianapolis, United States Health & Hospital Corporation of Marion County Full time
Division:Eskenazi Health

Sub-Division: FQHC

Req ID: 20488

Schedule: Full Time

Shift: Days

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis.

FLSA Status

Exempt

Job Role Summary

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
Job Requirements
  • 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
KNOWLEDGE, SKILLS, AND ABILITIES:
  • Investigative, decision making, problem solving, organization and analytical skills required
  • Ability to establish and maintain credibility and build effective relationships
  • Excellent verbal and written communication skills in interactions with various levels of management
  • Ability to present data at staff, peer, management and committee level
  • Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field
  • Demonstrated knowledge of quality management processes
  • Strong PC skills (including Excel, Access, Visio, other reporting database management systems) required
  • Working knowledge of Continuous Quality Improvement / Performance Improvement process
  • Ability to work independently; ability to facilitate groups and work within teams
  • Ability to facilitate change
  • Ability to prioritize, coordinate, organize and manage multiple tasks/priorities simultaneously
  • Positive self-starter and service-oriented individual
  • Detail-oriented with strong critical thinking skills
  • Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence
  • Ability to perform research through appropriate internet search engines
Knowledge, Skills & Abilities
  • Investigative, decision making, problem solving, organization and analytical skills required
  • Ability to establish and maintain credibility and build effective relationships
  • Excellent verbal and written communication skills in interactions with various levels of management
  • Ability to present data at staff, peer, management and committee level
  • Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field
  • Demonstrated knowledge of quality management processes
  • Strong PC skills (including Excel, Access, Visio, other reporting database management systems) required
  • Working knowledge of Continuous Quality Improvement / Performance Improvement process
  • Ability to work independently; ability to facilitate groups and work within teams
  • Ability to facilitate change
  • Ability to prioritize, coordinate, organize and manage multiple tasks/priorities simultaneously
  • Positive self-starter and service-oriented individual
  • Detail-oriented with strong critical thinking skills
  • Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence
  • Ability to perform research through appropriate internet search engines


Accredited by The Joint Commission and named as one of Indiana's best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute, Eskenazi Health's programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city's primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few.

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