Rn Quality Manager Qm

Description

0QM01

PVH employment application required. All job offers contingent upon background check and completion of pre-employment physical.

This is a full-time, salaried position scheduled for 32 hours per week.

• In collaboration with QI department team, assist in the implementation of the hospital-wide and Rural Health Clinic Quality Improvement Plan in accordance with standards set forth by regulatory agencies including but not limited to:
• The Joint Commission
• CDC
• Centers for Medicare and Medicaid Services (CMS)
• Community Care Partnership of Maine (CCPM )
• Monitor and evaluate any quality measure changes.
• Manage the publicly reported data process and internal requirements associated with publicly reported data.
• Coordinate the publicly reported data process including the collection, analysis, submission and reporting of CMS inpatient and outpatient measures.
• Work closely with departments during the data abstraction processes.
• Coordinate collaborative efforts to achieve hospital compliance with CMS core measure initiatives.
• Assist in the development and enhancement of data collection tools.
• Ensure regulatory compliance in all related activities and serve as resource for regulatory compliance.
• Provide support to clinical/operational quality improvement teams as assigned
• Facilitate QI teams, provide training and collaborate with team members in QI processes and methodologies.
• Provide staff support to teams (i.e. literature search, data collection, database maintenance, statistical analysis and data display methodologies).
• Write interpretive reports highlighting variations in clinical process and outcomes to identify improvement opportunities.
• Assist in the development and management of projects that employ a systematic method to identify, benchmark and integrate best demonstrated practices.
• Work with teams to identify and recommend process and documentation improvements.
• Supports the implementation and ongoing, organization wide, service excellence program as delegated.
• Participates in the implementation of ongoing education for leadership standards and employee standards of behavior.
• Monitors and reports patient experience data and collaboratively works with departments to develop action plans to enhance the patient’s experience based on established best practices.
• Fulfills identified tasks to sustain an organizational culture with a high focus on service excellence established tactics in all departments.
• Support physician peer review process related to quality-of-care reviews.
• Provide staff support to Committees that includes agenda and report preparation, maintain minutes, correspondence and follow-up on all action items.
• Ensure compliance with all regulatory agencies.
• Disseminate comparative clinical data that illustrates opportunities to reduce variation, improve outcomes and integrate best demonstrated practices.
• Perform routine chart reviews as defined by medical staff.
• Prepare individual physician profiles for periodic review including medical staff reappointment.
• Carry out the activities of the data management program as directed:
• Collect and validate data for identified key performance indicators per operational definitions for each metric.
• Compile and distribute reports per schedule.
• Utilize statistical tools for data presentation.
• Retrieve data from in-house electronic systems and other data sources to contribute.
• Participate in hospital-wide education on relevant quality improvement topics including New Staff and New Physician Orientation.
• Remain current on evidence-based practice and regulatory updates.
• Refer to hospital policy, accreditation standards and regulatory guidelines to guide recommendations or action plans.

Emergency/Disaster Management: As an employee of…