Job Summary

Facilitate the Quality Improvement process within the organization. Assist in presenting research and statistics, variances in protocols or practice in order to define standards of practice, and the development of specific protocols and indicators. Support the Service Group and medical staff clinical quality improvement efforts by providing expertise in the design and direction of studies related to quality of care, assessment and improvement, risk management and resource utilization in collaboration with committee chairs, clinical department chiefs, and facility department heads.

Responsibilities

• Oversee Quality Improvement (QI) activities from design, implementation, and data analysis to display, reporting and meeting preparation, maintaining close communication with physicians and appropriate management.
• Collaborate with management and staff to ensure consistent application of quality process across the continuum.
• Provide leadership and support to the organization to facilitate continuous clinical quality improvement theory and practice.
• Assist in the development and implementation of valid research tool and survey methodology. Assist with planning data collection and retrieval to facilitate efficient and collection of meaningful and valid data as indicated.
• Participate in preparing summaries and reports to teams, groups, committees as identified. Assist in writing study results, findings, conclusions and related manuscripts. Edit data utilizing appropriate soft packages. Recognize deficiencies in statistical data and take steps to validate and correct. Develop statistical analytical standards for data output to ensure high degree of accuracy.
• Seek reliable sources and maintain currency and availability of information related to healthcare statistics, comparative databases, specialty medical organization standards and guidelines for benchmarking.
• Participate in evaluation of the effectiveness of clinical quality, resource utilization and risk management programs by maintaining and providing overview and summary documentation and year to year comparisons of studies undertaken and results.
• Attend various meetings as assigned to present statistical feedback of data, defining trends and actions for improvement.
• Maintain department, institution, and licensure (if applicable) required education. Document appropriately.
• Demonstrate positive customer service and co-worker relations.
• Participate in the continuous quality improvement activities of the department and institution.
• Perform work in a cost effective manner.
• Perform related duties as assigned.
• Support the physician peer review process (ie. CPE) with information collection, documentation into specified ….., letter drafting, trending
• Data validation (ie. eCQM)

Knowledge, Skills & Abilities

Patient Group Knowledge (Only applies to positions with direct patient contact)

The employee must possess/obtain (by the end of the orientation period) and demonstrate the knowledge and skills necessary to provide developmentally appropriate assessment, treatment or care as defined by the department’s identified patient ages. Specifically the employee must be able to demonstrate competency in: 1) ability to obtain and interpret information in terms of patient needs; 2) knowledge of growth and development; and 3) understanding of the range of treatment needed by the patients.

Competency Statement

Must demonstrate competency through an initial orientation and ongoing competency validation to independently perform tasks and additional duties as specified in the job description and the unit/department specific competency checklist.

Common Duties and Responsibilities
(Essential duties common to all positions)

1. Maintain and document all applicable required education.
2. Demonstrate positive customer service and co-worker relations.
3. Comply with the company's attendance policy.
4. Participate in the continuous, quality improvement activities of the department and institution.
5. Perform work in a cost effective manner.
6. Perform work in accordance with all departmental pay practices and scheduling policies, including but not limited to, overtime, various shift work, and on-call situations.
7. Perform work in alignment with the overall mission and strategic plan of the organization.
8. Follow organizational and departmental policies and procedures, as applicable.
9. Perform related duties as assigned.

Education 

• Master's Degree (Required) Substitution: Bachelor’s degree and 3 additional years of experience in specialized area for the Master’s Degree requirement Experience: 7 years total experience with at least 5 years of broad base clinical nursing Basic computer skills, Microsoft Office

Credentials 

• Registered Nurse (Required)

Work Schedule: Days

Status:  Full Time Regular 1.0

Location: Memorial-MSOB

Location of Job: US:WV:Charleston

Talent Acquisition Specialist: Lauren R. Lane lauren.lane@vandaliahealth.org