In collaboration with the clinical lead, provides analytical support and coordinates quality management and performance improvement processes related to quality assessment; performance improvement; clinical documentation review; risk management; infection prevention and control; patient safety; and/or accreditation, regulation and licensing. Under the guidance of a program director or manager, responsible for collecting and researching data, performing data analysis, providing recommendations on data collection/reporting and presenting results.
Essential Functions:
- Partners with clinical quality service lines to identify issues within operations for focus improvement efforts.
- In collaboration with the clinical lead, coordinates on-going, multiple projects (e.g., supporting the clinical service line model).
- Develops timelines and agenda items.
- Helps identify best methods and processes for performance improvement, including developing project plans, facilitating group process and training related to data collection/reporting.
- Support groups through the full rapid improvement cycle.
- Helps identify and recommend actions to correct activities and processes.
- Analyzes, interprets information and makes recommendations on data collection.
- Presents data in a graphical format to support leadership groups and committees strategic planning and decision-making.
- Analyzes and compiles data into spreadsheets and databases.
- Helps identify and communicate alternative solutions to projects as needed.
- Abstracts data using Health Connect; runs reports and communicates results of analysis effectively to key stakeholders.
- Maintains and coordinates audits.
- Assists with developing audit methods to assess performance improvement and to ensure regulatory compliance.
- Based on audit results, creates and presents reports using various systems and databases (e.g., MIDAS focus studies).
- Supports workgroups or committees (e.g., peer review).
- Prepares meeting materials, including agendas and minutes; coordinates conference room logistics; monitors and follows up with action plans).
Secondary Functions:
- Mananges on -going multiple projects for Accreditation, Regulations and Licensing and Patient Safety Department.
- Analyzes, interprets information, and makes recommendations regarding The Joint Commission standards. Researches, complies, analyzes information into spreadsheets and databases.
- Serves as a resource to the committees.
- Designs communication plans to implement recommendations.
- Maintains and update survey binders.
- Identifies and recommends procedures to correct activities and processes.
- Develops and revises standards, policies, procedures and processes, such as improving the link between quality outcomes/improvement, risk management, and credentialing/privileges.
- Conducts audits and follow up on regulatory actions.
- Partners closely with Accreditation, Regulations and Licensing coordinators.
Qualifications:
Basic Qualifications:
- Demonstrated ability in managing databases, developing reports and data analysis using Excel and Access (3-5 years).
- Bachelor's degree in business administration, information technology or health care related field OR equivalent experience.
- Demonstrated knowledge of quality improvement; accreditation and licensing.
- Strong problem solving, project management and teamwork skills.
- Advanced skills with Microsoft applications (Word, Excel, Access and Power Point).
- Must be able to work in a Labor-Management partnership.
Preferred Qualifications:
Demonstrated knowledge of MIDAS andHealthConnect.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.