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    clinical quality specialist - Montgomery, United States - TriHealth

    TriHealth
    TriHealth Montgomery, United States

    1 week ago

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    Description

    Job Description

    Job Overview:


    This position works collaboratively with the Medical Staff Department / Section Chairs, Service Line System Chiefs, and Nursing leadership in the development and support of quality initiatives to improve patient outcomes.

    Facilitates peer review of clinical performance within QA Committees and initiates further activity to support Medical Staff and improve care delivery.

    Identifies and evaluates patient care issues using applied knowledge, clinical experience, and analytical skills.

    Works in collaboration with physician / practitioner and nursing leadership to implement Professional Practice Evaluation to meet Joint Commission accreditation compliance requirements of providers.

    Supports root cause analysis, apparent cause analysis and other applicable Patient Safety activities.


    Job Requirements:
    Bachelor's Degree in Nursing or Bachelor's Degree in Health Administration, other related field
    Registered Nurse
    Current Ohio licensure
    Cardiopulmonary Resuscitation (CPR)
    Basic Life Support
    Knowledge in field of specialty
    Knowledge of quality assessment, quality improvement techniques, i.e., medical chart review
    Excellent communication and customer service skills Experience in Data Analysis and Statistical Reporting
    3-4 years experience Clinical in Nursing in specialty area of patient care relevant to the assignment and other extensive clinical, medical/surgical, or critical care experience
    3-4 years experience Nursing in Quality Improvement and Medical Peer Review in a Healthcare setting


    Job Responsibilities:


    Collaborates with Medical Staff to perform physician peer review including FPPE and OPPE reviews in strict accordance with the established guidelines (TH and Joint Commission).

    Identifies trends and utilizes a proactive approach in notifying all Chairs for further follow-up and direction. Provides a summary incorporating assessment and analysis of FPPE findings and initiates appropriate corrective action. Reviews and evaluates patients' medical records and applies quality measures/criteria and utilizes hospital approved tools. Screens cases using clinical expertise and recommends referral for organized physician peer review. Provides necessary and appropriate follow through.

    Formally prepares and presents quality narrative and statistical reports in a clear and objective format for the Medical and Administrative Staff (as required).

    Analyzes and validates quality outcome data and reports trends by practitioner, service line, or procedure. Proficiently uses data systems, and skills with applications such as Excel, Word, and PowerPoint, and effective report development.

    Acts as staff and/or participating member of various Specialty Quality Committees; responsibilities may include agenda planning/meeting organization, coordinating follow-up as directed, and assisting in the development of methods/tools and/or process for implementing projects/programs that have the potential to positively impact the quality of patient care.

    Organizes and staffs all assigned clinical quality measures.

    Assists with the implementation of policies and procedures for the quality assurance and improvement function of TriHealth and assures compliance with The Joint Commission and other accrediting agencies and regulatory bodies.

    Facilitates commitment to an organization-wide quality structure and strategies for process improvement.

    This includes process development, data analysis and report preparation from the following databases:

    The Joint Commission/Centers for Medicaid and Medicare Services Core Measures, American College of Cardiology, Society of Thoracic Surgeons, Health Data Management, and Premier Clinical Advisor.

    Works collaboratively with other healthcare providers and ancillary services as part of the Healthcare Team to provide the necessary effective measurement and analysis of the patient care services received.

    Effectively communicates and responds to requests in a timely manner to support efforts aimed at problem identification and effective resolution.

    Understands the roles and responsibilities of the key players, quality champions, and customers. Serves as a source of knowledge for area of expertise. Adapts traditional methodologies within a changing business environment. Collaborates professionally with staff and agencies.

    Collaborates with Legal Counsel on matters associated with governing documents pertinent to the Medical Staff; assumes an active role for the dissemination of legal guidance and directives for system-wide alignment relative to peer review activities.

    Incorporates changes as needed to workflow designs, reducing system vulnerability through deliberate communication cascades and implementation of processes / practices throughout local department / section levels, including QA Committees.


    Other Job-Related Information:
    Indirect Report FTE's = 3-9


    Working Conditions:
    Climbing - Rarely
    Concentrating - Consistently

    Hearing:
    Conversation - Consistently


    Hearing:
    Other Sounds - Consistently

    Kneeling - Occasionally
    Lifting <10 Lbs. - Frequently
    Lifting 50+ Lbs. - Occasionally
    Lifting <50 Lbs. - Occasionally
    Pulling - Occasionally
    Pushing - Occasionally
    Reaching - Occasionally
    Reading - Consistently
    Sitting - Consistently
    Standing - Occasionally
    Stooping - Occasionally
    Talking - Consistently
    Thinking/Reasoning - Consistently
    Use of Hands - Consistently
    Color Vision - Consistently

    Visual Acuity:
    Far - Consistently


    Visual Acuity:
    Near - Consistently

    Walking - Consistently

    TriHealth SERVE Standards and ALWAYS Behaviors

    At TriHealth, we believe there is no responsibility more important than to SERVE our patients, our communities, and our fellow team members.

    To achieve our vision and mission, ALL TriHealth team members are expected to demonstrate and live the following:


    Serve:
    ALWAYS...


    • Welcome everyone by making eye contact, greeting with a smile, and saying "hello"
    • Acknowledge when patients/guests are lost and escort them to their destination or find someone who can assist
    • Refrain from using cell phones for personal reasons in public spaces or patient care areas

    Excel:
    ALWAYS...


    • Recognize and take personal responsibility to address and recover from service breakdowns when a customer's expectations have not been met
    • Offer patients and guests priority when waiting (lines, elevators)
    • Work on improving quality, safety, and service

    Respect:
    ALWAYS...


    • Respect cultural and spiritual differences and honor individual preferences.
    • Respect everyone's opinion and contribution, regardless of title/role.
    • Speak positively about my team members and other departments in front of patients and guests.

    Value:
    ALWAYS...


    • Value the time of others by striving to be on time, prepared and actively participating.
    • Pick up trash, ensuring the physical environment is clean and safe.
    • Be a good steward of our resources, using supplies and equipment efficiently and effectively, and will look for ways to avoid waste.

    Engage:
    ALWAYS...


    • Acknowledge wins and frequently thank team members and others for contributions.
    • Show courtesy and compassion with customers, team members and the community
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