Overview:CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U. S. , from clinics and hospitals to home-based care and virtual care services, CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources, CommonSpirit is committed to building healthy communities, advocating for those who are poor and vulnerable, and innovating how and where healing can happen, both inside our hospitals and out in the community.
ResponsibilitiesRN Quality Improvement Coordinator supports system-wide improvement initiatives within the facility to ensure effective and timely quality Improvement activities within a designated body of work, function, or specific clinical service line. The RN, QI Coordinator leads facility based evidence based Practice (EBP) Clinical Effectiveness teams using consistent standards and best practices to improve patient outcomes. The position utilizes trended quality data and analyzes to identify, design, plan and implement performance improvement initiatives in quality, safety and service measures. The role also promotes patient safety and participates in concurrent and retrospective monitoring of National Patient Safety Goals (NPSG) and other priority quality and safety indicators. The RN, QI Coordinator assists in maintaining a constant state of readiness around accreditation, regulatory preparation, including disease specific certification support.
The RN, QI Coordinator partners with nursing, physicians, and ancillary leaders and is an active member and facilitator of quality related committees focusing on improving care and outcomes. The position partners with the Medical Staff Office in overseeing appropriateness and quality of patient care through case review, peer review and the quality management process. The position supports the physician / service line department chairman with preparation of department meetings, identification of annual goals and maintenance of service line care standards. The position facilitates the establishment of a data driven culture in the clinical quality and operational areas.
Essential Key Job Responsibilities
G
lobal Quality & Patient Safety Support:
- Lead performance improvement (PI) initiatives consistent with organizational priorities and goals
- Demonstrate knowledge about pay for performance and quality transparency
- Coordinates clinical collaborative efforts to drive change in clinical practice and outcomes.
- Maintain knowledge of current and future trends in quality, safety, performance improvement, accreditation and healthcare economics while being attuned to the needs of patients, team members, physician, payers and regulatory bodies
- Support the Safetyfirst work and developing a Culture of Quality and Safety
- Participate in implementation of patient safety initiatives and promote National Patient Safety goals either separately or concurrently with other projects
- Partner with Risk Management to perform failure mode effects analyses in identifying high risk processes and systems to proactively promote safe care
- Partner with Risk Management to participate in the review / investigation and analysis of occurrence reports, causal factor data and determine action plans
- Integrate knowledge of external standards, including the Joint Commission and other state and federal regulations pertaining to quality
- Develop relationships with medical staff, clinical staff and leadership of clinical / non-clinical areas to improve core measure, associated outcomes and quality indicator performance.
Clinical Effectiveness, Evidence Based Practice Standards and Quality Review:
- Research literature or acceptable standards and guidelines to assist in development of practice guidelines (standing orders, policy/procedures, clinical pathways, protocols, etc
- Monitor quality performance, keenly identifying variation in the use of evidence based practice and to determine the need for peer review.
- Participate in the development and approval of clinical protocols and tools to support compliance with quality measures
- Implement and hard wire EBP, tools, tactics and techniques to improve clinical, operational and service excellence and help share best practices
- Support systems and standardization, while recognizing the individuality of each facility
- Conduct medical record mortality reviews using Institutes for Healthcare Improvement (IHI) based criteria; looking for common causes and trends
- Conduct medical record reviews and interventions for concurrent and retrospective hospital acquired conditions (HAC) and patient safety indicators (PSI
- Partner with Medical Staff Office in process of medical staff quality management programs, including peer review & Ongoing Professional Practice Evaluation (OPPE) and Focused
- Professional Practice Review (FPPE) quality information Perform concurrent or retrospective medical record review for quality concerns.
- Establishes timelines and exercises discretion and judgment when identifying concerns for review to improve processes.
- Supports several medical staff departments in performance improvement initiatives.
- Recommend areas for quality review; assist to identify high volume, high risk procedures across hospital and outpatient areas.
- Formulate appropriate review criteria and present for physician review and approval.
- Prepare data reports for medical staff quality initiatives utilizing current concepts in quality improvement methodologies.
- Assist in integrating data abstraction, quality monitoring, and reporting activities which support medical staff quality improvement activities compliance with Joint Commission and accrediting bodies
- Assist physicians with quality assessment reviews, prepare data and present reports to medical staff.
- Collect data through chart reviews, perform data analysis, and present information in an effective format to designated staff
- Evaluate potential standards of care that may need to be reviewed by medical staff. Areas include, but not limited to, patient / family grievances, team complaints, inpatient mortality, surgical / procedural complications and blood utilization.
Performance Improvement and Accreditation Support:
- Collaborate with clinicians and staff in developing and implementing processes to drive continuous improvement in clinical / ancillary departments
- Provide preparation and support for regulatory surveys; demonstrate knowledge of regulatory requirements for state and local agencies and disease specific certifications Facilitate and support performance improvement programs (nursing, interdisciplinary, etc) with the goal of ensuring practice improvement including establishing implementation plans, educational support, interfacing with managers and directors, and auditing of results
- Identify process variations and make suggestions for improvement to medical staff and quality related
- committees
- Track and review quality data and performance improvement indicators for specific service lines; include coordinating reporting of essential performance improvement and safety information for select committees
- Participate with colleagues and teammates to improve performance by actively challenging the status quo and continuously looking for improvement opportunities
- Assess for safety improvement opportunities and provide feedback to support these patient safety improvement activities
- Develop special knowledge base and/or experience in clinical service line; attend meetings to provide expertise for the service line teams
- Provide facilitation and leadership in specific clinical areas.
- Organize and coordinate meetings, identify patient quality and safety improvement opportunities and communicate results.
Clinical Abstraction, Data Entry, Analysis, Collection and Reporting:
- Demonstrate ability to present data and analyze and identify trends and patterns related to performance improvement, quality and safety data and activities
- Monitor reports for patterns and trends and act upon these appropriately
- Serve as a consultant to assist in identifying method of data collection - ie: a worksheet or data abstraction from Electronic Health Record (EHR), etc.
- Provide service line specific studies that require concurrent review, collection of data, and assistance in analyzing and sharing data
- Conduct quality related audits for select third party vendors providers to facilitate ongoing education and improvement to assigned populations.
- Apply quality improvement study design and implementation including selection of valid and reliable indicators, coordination of monitoring and evaluation activities, and medical record reviews.
- Analyze data and prepare concise, accurate and meaningful quality management reports in accordance with quality management principles
- Evaluate compliance with core measures including retrospective chart abstraction, outlier identification, dissemination of results and assistance in accompanying action plan;
- Partner with clinical informatics in providing consultation on core measures, quality and safety measures related to efficient and effective retrieval of data within the electronic health records
- Work in parallel with clinical Informatics to ensure that clinical care-related changes are also carried over into the Electronic EMR environment.
Consultation, Education and Support:
- Deliver education and training; serve as a subject matter expert in quality and safety related topics
- Serve as a consultant to assist in identifying appropriate methods and sources of data collection
- Establish local partnerships with medical staff, clinical staff and leadership of clinical / non-clinical areas to improve core measures and quality indicators performance.
- Collaborate daily with members of the healthcare team on issues requiring a high degree of diplomacy in one-on-one settings, as well as team and committee forums
- Precept and mentor new employees; provide ongoing education regarding quality and safety initiatives and performance improvement, "just-in-time" training to performance improvement teams regarding tools, techniques and methods, and provide assistance to departments in prioritizing and implementing performance improvement projects
- Provide educational programs related to quality and safety and areas of improvement for leadership, staff and the medical staff.
- Attend in-service training sessions and seminars to maintain and improve knowledge of performance improvement techniques
- Other duties assigned by manager
QualificationsRequired Education for Staff Job Levels
Bachelor's degree required, bachelor's degree in nursing preferred, will consider bachelor's degree in other healthcare related field (i.e: healthcare administration, business administration).
Will consider candidate that has an associate's degree in nursing and is currently in a bachelor's degree program or is willing to enroll and obtain a bachelor's degree within three years from date of hire.
Minimum of 3 years relevant clinical and quality work experience in a healthcare setting.
Required Licensure and Certifications
RN, with state license to practice required
PREFERRED Qualifications
Master's degree preferred.
Nationally recognized quality-related certification (ie: CPHQ, PMP, CJCP, CPPS).
Working knowledge of National Quality Forum (NQF), Agency for Healthcare Research and Quality (AHRQ), Institutes for Healthcare Improvement (IHI) safety indicators, serious reporting events, safe medical practices and Centers for Medicare and Medicaid Services (CMS) quality measures helpful.
Experience in quality improvement principles, performance improvement methodology, project management and change management.
Knowledge of regulatory and accrediting standards.
Strong project management skills.
Knowledge of regulatory and accrediting standards and Medical Staff Office.
Patient safety experience and work with High Reliability Organizations/ Systems.
Clinical knowledge and expertise in a clinical service line specialty.
Experience with Cerner, Allscripts, Meditech and other HER software systems.
Strong Information Technology- informatics knowledge.
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