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|Department:||Performance Improvement/Patient Safety|
This position will work with the Michigan Arthroplasty Registry Collaborative Quality Initiative (MARCQI).
Graduate of an accredited School of Registered Nursing and currently registered in good standing with the State of Michigan.
BA or BS degree in healthcare related field required. BSN preferred. For those hired into an RN position after January 1, 2009, it is required to obtain a BSN within ten years of their start date as an RN. Certification in the specialty area of practice is strongly encouraged.
Operating Room experience or experience caring for Orthopedic patients strongly preferred.
Minimum of three to five years of experience including clinical nursing experience in an acute care setting. Must demonstrate competency in the specific area of responsibility.
Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest in field of expertise. Demonstrates an ongoing commitment to learn.
Demonstrated leadership in process improvement and project management preferred.
Possesses comprehensive knowledge of the clinical capabilities of Munson Medical Center as well as thorough knowledge of hospital organization and department functions.
Excellent written and verbal communication/interpersonal skills and a positive customer relations philosophy.
Previous clinical chart review and abstraction experience preferred.
This position requires technical knowledge of hospital applications data-query software, ability to utilize and/or create databases, Windows-based word-processing documents, spreadsheets and report-generating software, presentation programs and other software relevant to the job. Internet skills and literature search capabilities required.
Self-directed; able to work effectively and efficiently with multiple interruptions and changing work priorities. Strong organizational and time management skills required. Able to make quality, independent decisions using analytical and problem solving skills. Demonstrates initiative and creativity in assigned work. Highly detailed and team oriented.
Demonstrates knowledge of confidentiality as it pertains to HIPAA and the handling of information sensitive to Munson Healthcare.
Provides administrative, technical, educational, and coordinating support to ensure effective, timely, hospital-wide quality assessment and performance improvement activities.
Under the direct supervision of the Administrator for Performance Improvement/ Patient Safety.
Collaborates with the Administrator of Performance Improvement/Patient Safety to prepare required (regularly scheduled and ad hoc) reports to the Quality Committee of the Board of Directors, Medical Staff committees, and Hospital Departments as appropriate.
May report directly to the VPMA, Medical Staff Leadership, and peer review/performance improvement committee leaders
Age of Patients Served
No clinical contact
1. Supports the mission statement of Munson Medical Center (MMC).
2. Embraces and supports the Performance Improvement philosophy of Munson Medical Center. We will provide services that meet our customers’ requirements every time.
3. Is authorized to provide individual case review, and aggregate data, by the Board, Vice President Legal Affairs, Vice President Medical Affairs, and all peer review/quality improvement committees.
4. Promotes personal and patient safety. Knows the physical requirements of the job and works within those guidelines. Performs job duties safely at all times, utilizing learned body mechanics and ergonomics. Plans actions to promote safety. Reports any unsafe situation/equipment according to Hospital procedure.
5. Utilizes principles of Relationship-Based Care (RBC), meets expectations outlined in Commitment To My Co-workers, and supports RBC unit action plans.
6. Demonstrates effective customer service/interpersonal skills at all times. Applies techniques of problem solving, active listening, negotiation and strong consensus building skills. Employs a high level of tact and diplomacy; able to diffuse emotions when working on sensitive quality-oriented physician issues.
7. Promotes use of risk reduction strategies. Serves as a role model for patient quality and safety throughout the organization. Works with multidisciplinary teams to identify and investigate patient care quality/safety issues, events, or trends; recommends prevention strategies to improve healthcare delivery using process improvement techniques (e.g., root cause analysis, control and run charts).
a) Notifies direct supervisor of infractions of policy, procedure, laws and regulations as they are identified.
b) Notifies Accreditation Resources and/or Corporate Compliance Officer of any issues that continue to be unresolved.
8. Maintains knowledge of current PI methodologies and clinical informatics through regular review of literature, conference attendance, participation in professional organizations, etc.
a) Analyzes, interprets and synthesizes relevant literature and research studies to maintain knowledge of updated and current practices in specific area of interest.
b) Provides customers with up to date information relevant to Performance Improvement and specific area of responsibility.
c) Understands concepts of Six Sigma/Lean principles and tools.
d) Maintains baseline knowledge of Joint Commission standards, National Patient Safety Goals, and other regulatory requirements impacting matters within the assigned scope of responsibility; ensures that these factors are considered and integrated into PI activities.
9. Collects, analyzes and reports clinical data elements on eligible cases as required for participation in MARCQI, a Blue Cross Blue Shield of Michigan funded Collaborative Quality Initiative.
a) Will actively participate in MARCQI activities and identify opportunities to improve the quality of care
b) Will work with physicians, nurses, other clinicians and administrators to develop strategies to improve performance.
c) Requires attendance at Consortium-wide meetings and data abstraction meetings.
d) Responsible for preparing for site audits
e) Responsible for resolving data discrepancies and responding to MARCQI Coordinating Center requests in a timely fashion.
10. Develops, designs, and maintains relevant electronic data systems (i.e. clinical data systems that support facility information needs for the purpose of performance improvement and assessment of clinical quality/patient safety).
a) Assists in design, installation, implementation and evaluation of existing or new database applications, tables and files.
b) Oversees the performance of day-to-day operation and maintenance of software systems to include updates of the system as indicated, including periodic testing of integrity of the systems/data.
c) Recommends improvements to the systems as needed.
11. Comprehends data, trends, and measurement outcomes. Communicates complicated concepts in a clear and understandable manner to health care professionals both verbally and in written form. Able to present to individual providers as well as groups, both internal and external as requested.
a) Manages data maintaining high standards for accuracy and assuring data integrity.
b) Develops and implements data collection processes: provides research, benchmarking, analysis and summary
c) Assists in the development of outcome assessment tools for the continuum of care. Responsible for analyzing and reporting patient care outcomes data from various databases and identifying plans for improving outcomes, length of stay, and resource utilization.
d) Conducts thorough analysis of patient care and outcomes through medical record abstraction and review.
e) Interprets abstracted information to develop reports. Produces analysis and trending reports that include graphic presentations and statistical summaries for use by management, and/or clinical staff as well as appropriate facility, system, and external customers in accordance with established timelines. Composes grammatically correct and technically accurate case review summaries and reports.
f) Provides periodic data quality reports (DQRs) for external customers as required.
g) Validates data analysis generated internally and externally for reasonableness and accuracy, using knowledge and experience.
h) Coordinates and participates in periodic audit by external review agencies and data registry personnel.
12. Identifies processes, outcomes and trends where improvements could be made and proposes recommendations.
a) Collaborates with medical staff, nursing, and ancillary services in the application of continuous performance improvement principles, standards and tools.
b) Facilitates application of problem-solving methodologies, emphasizing the effectiveness and efficiency of evidence-based and data-based decision-making in performance improvement activities.
c) Establishes standards and procedures for projects such as tracking, reporting, recordkeeping and documentation; monitors progress on key quality initiatives and indicators, leading towards achievement of department, service line, and organizational goals. Keeps appropriate parties apprised of overall progress and monitors project results for significant deviations; proposes workarounds and alternative actions to ensure that timelines and deliverables are met; reviews project deliverables to ensure they meet standards and objectives.
d) Assists in the development and revision of critical pathways and trending of variances as appropriate.
13. Serves as a resource to colleagues throughout the medical center.
a) Collaborates with leadership to identify and discuss performance improvement
strategies and opportunities as they relate to organizational mission, vision, and values,
clinical outcomes, and patient safety goals.
b) Analyzes and assesses clinical practices for opportunities to improve healthcare delivery.
gains consensus as to performance improvement projects to be undertaken; assists in the
development and evaluation of standards, procedures, processes, and automated tools that
support established goals and regulatory requirements.
c) Serves on hospital, professional, and community committees as appropriate; provides
ongoing consultation and education for hospital policies, procedures and PI/Patient Safety programs/activities designed to meet regulatory and accrediting agency requirements (i.e. Joint Commission, CMS, IHI, DHHS, and Peer Review organizations)
d) Serves as representative of PI Department at Medical Staff and hospital committees as
e) Assists in identification of educational needs of medical and nursing staff through
participation in data registries and subsequent outcome analysis. Communicates identified
educational needs to CME Coordinator and Staff Development personnel.
f) Assists in development and/or presentation of continuing education related to specific area
14. Supports physician sections/departments and peer review activities.
a) Coordinates peer review activities for the medical staff by screening medical records and PEERS reports for adverse outcomes in accordance to medical department definitions.
b) Submits cases for peer review as warranted.
c) Coordinates and attends multi-disciplinary peer review meetings: tracking attendance, writing meeting minutes and submitting an annual report
d) Organizes external peer review activities in accordance with medical staff bylaws and peer review process.
e) Conducts ongoing physician-specific focused review in accordance with medical staff bylaws and physician credentialing process.
f) Meets regularly and on ad hoc basis with Department Chairs, Sections Chiefs, Peer Review Committee chairs and Medical Quality Assurance Officers in support of medical staff performance improvement activities.
g) Serves as liaison between Chairperson of Peer Review Committee/Medical Department Quality Officers and the Medical Director of Quality/Performance Improvement Committee.
h) Provides patient outcomes information and physician-specific outcomes data for medical staff performance improvement activities and credentialing and reappointment.
i) Collaborates/communicates with the medical staff leaders and the manager of Medical Staff Services regarding the Ongoing Professional Practice Evaluation (OPPE), as well as Focused Professional Practice Evaluation (FPPE), of members of the medical staff. Uses medical staff database to document pertinent peer review activity.
g) Provides orientation to new members of the medical staff regarding department-specific outcomes, quality goals, and the MMC peer review process.
h) Assures confidentiality and integrity of all medical department performance improvement and peer review activities.
15. Acts as a resource for Administrative/Departmental requests in the absence of the Administrator of PI/Patient Safety.
16. Performs other duties and responsibilities as assigned.
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