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  • Executive Director

    3 days ago


    Weymouth, United States South Shore Health Full time

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Performance Improvement Specialist-Trauma Program

2 months ago


Weymouth, United States South Shore Health Full time

Job Description Summary Under the direction of the Trauma Program Manager, this position plays a pivotal role in ensuring that the Trauma Program at South Shore Hospital performs at the highest levels on hospital, national and American College of Surgeon (ACS) specific measures of clinical care quality and system performance. The Trauma Performance Improvement Specialist RN is responsible to ensure the accurate and timely collection of data from electronic medical records, identifies opportunities for improvement, communicates and works with multidisciplinary stakeholders and facilitates the coordination and implementation of evidence-based, data driven, quality improvement initiatives with measurable improvements in trauma care processes and outcomes. (Salary Range: 60-100k annually) Job Description Essential Functions 1 - Encourages an atmosphere of individual, team, and organization wide performance improvement. a - Performs data collection for identifying baseline performance of team members. b - Selects assessments/reports for review based on epic reports, trauma data registry reports, and/or random sampling methods. c - Educates staff regarding their role in improving patient outcomes and appropriate coding using ICD 10 coding guidelines. d - Increases staff knowledge and awareness through utilization of monthly trauma program meetings, accepted internal modes of broadcast (i.e. newsletters. Email blasts, presentations) e - Supports staff through participation in the design and education of new documentation tools and processes. f - Tracks documentation reviews/findings by team/department. g - Initiates and/or participates in minimally two Performance Improvement studies/year. h - Reviews and compiles data for variance tracking. 2 - Reviews, evaluates, synthesizes and interprets various program and trauma patient specific data from internal and external sources to promote program and patient outcomes, efficacy, and quality care a - Promotes an understanding of OBQI/OBQM/QAPI through oversight and analysis of data collection from a variety of data platforms b - Performs concurrent and retrospective trauma data audit filter reviews c - Screens for inconsistencies between patient outcomes and data filters/data sources d - Collects/tracks data findings by team/department in order to determine the need for ongoing staff education e - Reviews and corrects assigned interfaces produced by the software program as needed. f - Utilizes appropriate statistical techniques to analyze and display data as evidenced by completed graphs and charts. g. Assist with trauma program and system-level quality improvement projects including project scope and design, process redesign, implementation testing establishment of performance metrics and the development of sustainable plans h- Responsible for managing and developing databanks to track operational performance and promoting/developing data-drive quality improvement initiatives i-Monitors progress on QI projects j-Manages project timelines, agenda development, minutes and documents, slide decks and preparation of reports on project status and activities for various audiences k-Actively participates in American College of Surgeons reverification readiness preparation and reviews l- monitor and trend data to assess and identify opportunities for strategic program goals m-Assist with benchmark data preparation, trauma registry report preparation and clinical indicators review 3 – Supports, develops and monitors efficiency and performance of trauma registry activities a - Participates in educational programs to update trauma program team knowledge and proficiency of coding principles and data abstraction processes. b - Ensures the primary diagnosis and secondary codes accurately reflect the diagnosis of the trauma patient. c – monitors coding and scoring of trauma registry entries to ensure accuracy and to identify data trends and opportunities for improvement d- continually assists with innovating trauma registry design, organization and workflow to optimize efficiency and data accuracy e- monitors and evaluates the integrity of TQIP and state data submissions f- collaborates with trauma registrars to review validation reports, problem-solve and correct report rejections g- develops semi-annual or annual reports based on trends or significant changes in data requirements/availability which may require intervention 4 - Develops and continuously expands in depth knowledge of ACS reverification criteria a - Establish/maintain process for tracking changes and/or additions to data audit filters as required by ACS b – Conducts annual review of trauma data audit filters for accuracy and completeness c - Communicate with responsible staff member/manager for clarification and follow up whenever necessary d - Communicates changes in reverification criteria to supervisor and staff as directed 5 - Provides technical IS application support. a - Collaborates with IS Applications Specialist and/or appropriate vendors to resolve trauma registry software issues b - Investigates and resolves electronic documentation problems as needed c - Monitors software program documentation problems and identifies trends d - Communicates needs/problems to IS Application Specialist/Customer Support Center (CSC) and software vendor as needed. 6 - Maintains own professional growth and development. a - Maintains current applicable licenses and certifications. b - Participates in monthly trauma program and other relevant meetings as outlined by the Trauma Program Manager. c - Attends and participates in Department/Team Meetings. d - Demonstrates effective communication, interpersonal and presentation skills. e - Champions ACS readiness at all times. f - Demonstrates initiative. g - Consistently organized, meets deadlines h- Participates in pertinent professional education to maintain current knowledge of best improvement practices specific to the trauma/injured patient population 7 - Technology- Embraces technological solutions to work processes and practices. a - Demonstrates clinical proficiency and competency in the electronic medical record as evidenced by successful completion of competency based orientation and appropriate daily utilization of software. b - Utilizes information systems and telecommunication services as instructed, this includes phones, voicemail, pagers and cell phones as assigned. c - Demonstrates the ability to write concise, informative reports and create charts/ graphs, using the current available programs. 8 - Safety Awareness- Fosters a “Culture of Safety” through personal ownership and commitment to a safe environment. a - Exhibits knowledge and understanding of ACS standards. b - Assures organizational clinical practice guidelines are adhered to as evidenced by documentation in the medical record. c - Demonstrates understanding of the emergency preparedness plan as evidenced by participation in agency drills and discussion at team meetings. d - Complies with current CDC hand hygiene guidelines through proper hand washing as observed by managers and peers. e - Exhibits knowledge and understanding of the use of personal protective equipment. f - Adheres to respiratory etiquette guidelines. g - Handles hazardous waste according to protocol. h - Utilizes proper body mechanics when performing all aspects of job. i - Adheres to electrical safety guidelines. j - Maintains a neat, organized environment. PHYSICAL REQUIREMENTS General Activity - Frequent Standing/Walking Required, Frequent Driving Required Motion - Frequent Activity Required-lifting, bending Motor Skills - Use of hands required, Use of feet required Weight/Force - Light lifting required ( Preferred Master of Science Degree in Public Health or Equivalent; Master’s of Science Degree in Nursing from an NLN–approved school of nursing or Equivalent. MINIMUM EDUCATION-Required Bachelor of Science Degree in Nursing from an NLN-approved school of nursing or equivalent. Minimum Work Experience Three (3) to five (5) years of experience in a healthcare setting; minimum of 1 year of experience in quality improvement or process improvement in a hospital or comparable environment preferred Required Licenses / Registrations/ Certifications Lean/Six Sigma Certificate or Equivalent preferred Licensed Registered Nurse RN in the State of MA if applicable to experience Required additional Knowledge and Abilities Knowledge of and experience utilizing PI process and process evaluation techniques (FMEA) Lean and/or IHI Model for Improvement Familiarity with electronic health record system Epic and Epic reporting preferred Demonstrated ability to interpret qualitative and quantitative data. Prepares cogent reports facilitating decision-making. Facilitates innovation and is able to motivate groups towards solutions. Creative thinking and problem-solving skills Knowledge of American College of Surgeon trauma program standards and other regulatory standards and ability to interpret the standards. Proficient with computerized software systems and technology. Excellent verbal and written communication skills Ability to multi-task under stressful situations/environment. Detailed oriented Solid Organizational skills Strong interpersonal skills; ability to establish supportive, collegial relationships

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