Job Summary

Performs review of patient records for quality of patient care in conformance with established criteria and identifies and implements performance improvement activities. Helps to assure appropriate patient outcomes in a timely and cost-effective manner. Actively initiates, develops, and monitors quality indicators and performance improvement opportunities. Performs retrospective and concurrent review of records to meet the requirements for all National Hospital Inpatient Quality Measures, including but not limited to Joint Commission Core Measures, CMS Scope of Work, Magnet, NDNQI and American College of Cardiology's Action Registry. Assists hospital staff to remain in a state of constant readiness for a Joint Commission accreditation survey. Expert in Quality/Process Improvement methodologies.

Essential Functions:

* Performs retrospective and concurrent review of core measure patients in compliance with National Hospital Inpatient Quality Measures and regulatory agencies such as Joint Commission, CMS, State Regulatory agencies and voluntary Accreditation programs.

* Reports required data electronically on regular basis as required to QNET/ACC/TJC/CMS/MHCC.

* Expert in core measures, CMS and TJC requirements informing director of changes in protocol/data requirements and implications for clinical practice.

* Educates medical staff, employees, leadership and Board of changes in various measures protocol/data requirements and implications for clinical practice.

* Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis and other studies) requested by medical staff, hospital departments and committees.

* Flags and documents variances for selected indicators and variables for focused studies and implements indicators for medical staff peer review including OPPE and FPPE required by TJC.

* Premier's Physician Focus subject matter expert - works closely with our Premier clinical partner and AVPMA for OPPE/FPPE to collect data and present goals/expectations and peer group comparisons to the Medical staff.

* Premier / Financial data monthly and quarterly uploads that is publicly reported and also sent to CMS and The Joint Commission.

* Provides continued improvement consulting services to customers.

* Collects, interprets and reports data at specified intervals with 99% accuracy and completeness.

* Identifies and interprets objective and subjective data found in the medical records.

* Compares the identified data to established criteria to determine appropriateness of care.

* Abstracts and reports PI information in appropriate format to detect patterns and/or problems in the delivery of care.

* Identifies potential areas for change and improvement of the study design and data collection and makes recommendations.

* Develops new ongoing quality projects and evaluates the appropriateness of indicators and criteria for quality monitoring.

* Maintains current knowledge of PI strategies, principles, methodologies, techniques and data analysis.

* Maintains current knowledge of TJC, CMS, ACC national quality indicator guidelines, and assesses compliance for assigned areas.

* Works with Leaders, Chiefs, Vice Chiefs and Committee Chairs to organize and accomplish goals of required committee meetings, collaboratives and teams.

* Executes effective improvement projects through multidisciplinary team collaboration.

* Active participant in meetings and provides reports and information as required by the committee or team and meets required attendance.

* Assures that issues are communicated to appropriate committees or individuals and that issues have timely resolution.

* Maintains peer review information in strict confidentiality and assures entry into database and PI file.

* Supports ARC and notifies regarding types of cases that constitute Level I reportable events to the Maryland Office of Healthcare Quality.

* Notifies the Patient Safety Officer regarding reportable or potentially reportable events in a timely fashion.

* Attends RCA's and FMEA's related to their subject matter.

* Assists in the investigation of reportable or potentially reportable events.

* Assists with Leading teams to identify areas of potential breach of patient safety and create solutions to eliminate such breaches.

* Facilitates and/ or leads projects related to identified areas in need of process improvement.

* Facility provides the structure, process and personnel to obtain and maintain the quality standards of the MBSAQIP in caring for metabolic and bariatric surgical patients. The administrative and medical staff commit to broad cooperation in order to improve the quality of metabolic and bariatric surgical care provided at the center.

* Collect and submit accurate, complete and timely data to the MBSAQIP Data Registry platform. This is accomplished through high-quality data compilation, documentation, and entry of 100% of metabolic and bariatric procedures performed at the Center into the MBSAQIP Data Registry Platform.

* Works closely with the members of the metabolic and bariatric and general surgery departments to identify opportunities for clinical quality improvement and other special projects that may be identified.

* Successfully completes the MBSCR Online Training Program

* Participates in program teleconferences

* Participates in data compilation for audits and re-accreditation or site visits.

* Periodically attends voluntarily in-person professional development seminars offered at annual meetings such as ASMBS, ACS NSQIP, or ACS Clinical Congress.

* Primary Competencies:

* Clinical Knowledge: Data collection and identification of areas for quality improvement requires clinical knowledge and understanding of patient care. The candidate should have some clinical understanding as well as access to a clinical mentor who can advise when clinical questions arise.

* Computer Knowledge: The ability to learn and utilize new software and web applications for data entry and report generation. The candidate should have some computer experience with Microsoft Office and basic statistical skills.

* Hospital Systems knowledge: The ability to track health information through various sources such as medical records, surgery clinics, death index, direct patient contact, accounts payable, and legal counsel. The candidate should have some experience gathering information in a complex hospital system environment.

* Hospital Departmental Knowledge: The ability to identify opportunities to report metabolic and bariatric data to relevant groups or meetings (for example, morbidity and mortality, infection control, quality management, and administration. The candidate should have some experience sharing information across functions.

* Data Collection and Reporting:

* Identifies 100% of metabolic and bariatric surgery patients for inclusion in MBSAQIP data registry.

* Collects preoperative, intraoperative, 30-day postoperative, and long-term (six month and annual thereafter) follow -up data components for the program through the effective utilization of the hospital medical record systems and through a coordinated effort with individual surgeon office staff.

* Identifies streamlining and process improvement opportunities in the data collection process.

* Demonstrates appropriate utilization of resources necessary to obtain valid, reliable data for entry into the program.

* Utilizes software applications for data collection and analysis.

* Responsible for the accurate, complete and timely entry of data into the program's database.

* Work effectively with Hospital and individual Surgeon Office Staff:

* Establishes effective working relationships with members of the hospital community, especially staff in the surgery, medicine, nursing, medical records, and information systems departments and individual bariatric surgeons' offices whose support is necessary for the management and success of the program.

* Serves as an educational resource on the MBSAQIP Data Registry Platform for internal and external audiences by developing educational material and delivering presentations.

* Conducts routine assessment of products to determine needs, variations, and improvements required.

* Assures complete, efficient and effective usage of all of the Verge Products including Credentialing, Peer Review, Patient Relations, Event Reporting, Compliance Rounding/Findings, and reporting (Insights)

* Assures maximum optimization of each product. Assures that enhancements are utilized.

* Maintains databases and processes in the system. This includes maintaining user accounts, permissions, and areas of responsibility.

* Identifies potential areas for change and improvement of the system and makes recommendations.

* Communicates system upgrades and downtimes as necessary.

* Develops new ongoing quality projects and evaluates the appropriateness of use of the system to affect change and improve processes.

* Identifies and interprets objective and subjective data found in the Verge Products.

* Triage all Event Reports and assure proper delineation and accuracy.

* Maintain Intranet Page for data, tips of the week, training schedules, etc.

* Create monthly report of events with drill downs for Operations Council.

* Evaluate event types and determine potential trends. Forward these issues to the appropriate individuals and teams including use for possible RCA or FMEA.

* Evaluate event types and determine appropriate reports. Build the reports and assure that they are distributed to all necessary individuals and groups. Provide routine reports monthly to necessary teams and individuals.

* Meet with Leaders to identify needs and make improvements. Leaders includes: department managers/directors, team leaders, and system leaders.

* Chair Verge Steering Committee

* Assure that leaders are completing their reports timely. This would include review of reports.

* Assure that Peer Review/Medical Staff Review is completed timely and accurately.

* Assure Peer Review is forwarded from the Peer Review to Credentialing

* Work with HR to assure that the user database is accurate and new users are added timely. Assure that the product is maintained and current.

* Build and/or revise various audit tools, event types, and other databases to meet the customer's needs while following the approved process and policy.

* Maintain policies and procedures with necessary changes as needed.

* Keep current on each product and assure efficient and effective use of the system.

* Assure that there is flow of data/information throughout the Verge Solutions products.

* Submit tickets to Verge and communicate with Verge at least bi-weekly

* Assure that the process is working for end users. This would include data entry, reports, and views for leaders.

* Assure that standards are attached to data collection tools.

* Conduct routine training for leaders and staff. Conduct focused training for various groups such as nursing, leaders, staff entry, new managers, etc.

* Write articles as needed for different publications

* Work closely with Privacy Officer for reporting needs quarterly; Work with Service Excellence Department for system needs

* Attend Patient Safety and prepare dashboard for Committee

* Run data and update PSO database

* Work with Finance to submit Premier data & error reports

* Work with Frederick Health Medical Group and Home Health for process improvement initiatives

* Support various Lean projects and mentor individuals pursuing Lean for Leaders

Required Knowledge, Skills and Abilities:

* Strong clinical knowledge and critical thinking skill to evaluate appropriateness of clinical practice, including diagnosis, treatment and surgical procedures for varieties of disease and disorders.

* Excellent communication skills, both verbal and written.

* Strong organizational skills and ability to prioritize and manage multiple tasks.

* Interacts with physicians, nurses, department heads and others while identifying quality of care issues.

* Applies creative problem solving, identify errors of omission, and utilize resources effectively.

* Knowledge of computer software and able to complete data entry from PC database applications.

* Proficiency and accuracy in the use of software programs such as MS Word, Excel, PowerPoint, and Outlook.

* Works professionally with a diverse population base.

* Maintains a high level of confidentiality.

Minimum Education, Training, and Experience Required:

* Registered nurse from an accredited school of nursing or healthcare professional from an accredited school required.

* Bachelor's degree in nursing, information systems or health care related field required.

* Three to five years of experience in either nursing in an acute care hospital, (preferable in medical/surgical, pediatrics/OB, oncology, psych, or critical care) OR with current experience in Performance Improvement with knowledge of procedures, treatments and medications in those areas.

* Certification as a CPHQ, or another specialty, such as CPPS or HCAP, is required within 2 years of employment.

* Previous experience in performance improvement is desirable but not required.

* Lean/Six Sigma experience or certification preferable.

Patient Contact

Must demonstrate and maintain current knowledge and skills in providing appropriate care/contact for patients in the following age groups:

N/A

Must demonstrate knowledge of the principles of growth and development over the life span and possess the ability to assess data reflective of the patient's status. Possess the ability to interpret the appropriate information needed to identify each patient's requirements relative to his/her age-specific needs and to provide the care needed as described in the unit's/department's policies and procedures - Not applicable.

Physical Demands:

Sedentary - Light Work - Lifting up to 15 pounds on an infrequent basis (less than one lift every three minutes). While work is mostly done sitting, a certain amount of walking or standing is often necessary.

Ergonomic Risk Factors:

Repetition: Repeating the same motion over and over again places stress on the muscles and tendons. The severity of risk depends on how often the action is repeated, the speed of the movement, the required force and muscles involved.

Awkward Posture: Posture is the position your body is in and its effect on the muscle groups that are involved in the physical activity. Awkward postures include repeated or prolonged reaching, twisting, bending, kneeling, squatting, working overhead with your hands or arms, or holding fixed positions.

Working Conditions:

Bloodborne Pathogens Exposure Risk: Category C - NO exposure to blood or body fluids.

Reporting Relationship:

Reports directly to Manager of Performance Improvement

Schedule:

Part time position - 40hrs per pay (20 hrs per week)

Monday through Friday dayshift 8am-430pm with flexibility in hours. Some evening or early meetings required.