- Assists in the design, planning, implementation and coordination of Quality Management, Patient Safety and Performance Improvement activities for assigned hospital and medical staff departments, committees, divisions, service lines and functions.
- Proactively coordinates and facilitates performance improvement teams to support key initiatives, including but not limited to, activities focused on clinical quality improvement, patient safety and risk reduction, patient experience, efficiency, FMEAS, and root cause analyses and medical staff improvement (e.g. OPPE, FPPE).
- Participates in an integral role to ensure compliance with CMS HIQRP/HOQRP, TJC, Leapfrog, etc., data collection and reporting of process and outcome measures.
- Facilitates development and implementation of data collection tools and processes including the ability to: identify data elements needed to complete appropriate measurement, perform data collection and abstraction per specifications, and validate data prior to submission or preview reports prior to publication.
- Facilitates meetings, presents data and reports, identifies key findings and assists with action plans and implementation.
- Maintains current knowledge of accreditation and licensing requirements and must be a resource to staff on these regulations in order to improve management of outcomes and ensure compliance.
- Assists with regulatory readiness and survey preparation activities including mock survey tracers.
- The job summary and responsibilities listed above are designed to indicate the general nature of the work performed within this job. They are not designed to contain or be interpreted as a comprehensive inventory of all job responsibilities required of employees assigned to this job.
- Employees may be required to perform other duties as assigned. Qualifications
- Bachelor's degree or five (5) years of related job or industry experience in lieu of degree.
- One (1) year healthcare-related quality management/performance improvement experience (e.g., chart audit, PI team member, etc.) and three (3) years clinical experience in an acute care setting
- Knowledge and expertise of quality management/performance
improvement methods, tools, and techniques (e.g. PDSA, Tests
of Change, Six Sigma, LEAN) and ability to create and support an
environment that meets the quality goals of the organization. - Current knowledge of data reporting and
regulatory/accreditation requirements for acute and ambulatory
care services and federal, state and local healthcare related laws
and regulations and the ability to comply with these in
healthcare practices and activities. - Knowledge of effective self-management practices and ability to
manage multiple concurrent objectives, projects, groups, or
activities, making effective judgments as to prioritizing and time
allocation. - Understanding of the necessity and value of accuracy and
attention to detail - Knowledge of the techniques and the ability to work with a
variety of individuals and groups in a constructive and
collaborative manner. - Knowledge of the current situation or issue at hand; ability to
take full personal responsibility or ownership for assignments,
activities, decisions and results. - Knowledge of techniques and tools that promote effective
analysis and the ability to determine the root cause of
organizational problems and create alternative solutions that
resolve the problems in the best interest of the business. - Ability to work well under pressure and respond to changing
needs and complex environments - Excellent communication skills (oral and written), presentation
style, including the ability to concisely present data to leaders,
clinicians and staff at all levels of the organization -
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Responsibilities
Required Education and Experience
Certified Professional in Healthcare Quality (CPHQ), or Healthcare Quality and Management Certification (HCQM), or Certificate of Professional Healthcare Quality and Patient Safety (CPQPS) within 2 years of employment is required.
Required Minimum Knowledge, Skills, Abilities and Training
