Quality Outcomes and Leapfrog Coord, Marshall Medical Center North, Quality Management

Overview

This position will report to the Director of Quality through the Patient Safety & Performance Improvement Coordinator.

The Quality Outcomes and Leapfrog Coordinator Essential Functions are comprised of 3 domains:
Quality Outcomes Monitoring, Leapfrog Coordination and Performance Improvement Initiatives.

OUALITY OUTCOMES MONITORING

• Monitor and support facility performance on national quality programs including:
  • CMS Hospital Star Ratings
  • Hospital Value-Based Purchasing (HVBP)
  • Hospital-Acquired Conditions Reduction Program (HACRP)
  • Hospital Readmissions Reduction Program (HRRP)
  • Hospital Compare
  • The Joint Commission
• Ensure alignment and integration of Leapfrog improvement strategies with other hospital quality initiatives
• Identify overlapping metrics, data sources and improvement opportunities to maximize efficiency and impact across quality reporting programs
• Identify gaps in care and collaborate with departments to address them
• Ensure accurate reporting to internal stakeholders and external regulatory agencies

LEAPFROG COORDINATION

• Manage and oversee the accurate and timely completion of the Leapfrog Hospital Survey for both facilities
• Serve as an internal resource for directors/managers related to the required data collection and validation for Leapfrog metrics, and provide necessary education and consultation as needed
• Coordinate with clinical and operational departments to gather and validate the required data for Leapfrog metrics
• Monitor MMCs performance against Leapfrog standards and develop action plans for improvement
• Monitor changes in Leapfrog methodologies and scoring, communicate updates to department leadership and ensure alignment across facilities
• Attend conferences, webinars and education sessions to prepare for the survey submission
• Maintain a database of submissions and scores by facility with a goal of incrementally improving scores
• Maintain documentation required in the event of audit
• Expected to obtain Leapfrog Coach Certification within 6 months of hire

PERFORMANCE IMPROVEMENT

Performance improvement sets Specific, Measurable, Attainable, Realistic, and Time-Sensitive (SMART) goals and utilizes the Plan Do Check Adjust (PDCA) PI model

• Act as Subject Matter Expert for Leapfrog submission for all service lines in performance improvement initiatives
• Meet with leaders on a regular basis to ensure they understand the data requested of them and make improvements/adjustments as needed to meet goals and targets
• Provide periodic updates to leadership and hospital staff regarding current status and opportunities for improvement
  
  Conduct data analysis, reporting, information sharing, and performance improvement including departmental follow-up when needed
• Create customized reports and presentations as required
• Use methodologies such as Lean, Six Sigma, PDCA to improve patient care processes
• Participate in setting aggressive, yet attainable benchmarking goals with measurable objectives and assist in the achievement of these goals
• Assist with data tracking, graphs, presentations, and recognition programs

Requirement
:

Bachelor’s degree in Nursing, Healthcare Administration, Public Health or other clinical field.

OR

Associate’s degree in Nursing, Healthcare Administration, Public Health or other clinical field, and

At least 5 years hospital or healthcare experience or related industry.

Strong background in improving clinical outcomes

Significant experience in coordinating and executing cross-functional team projects

Preferred

Master’s degree or higher level in a clinical field

10+ years hospital or healthcare experience