Clinical Quality Specialist

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

• Develops and maintains current knowledge of CMS and State quality measure requirements to include data interpretation and application to effectively evaluate compliance with all measures.
• Serves as a resource for CMS quality programs to include IQR, OQR, PI, VBP, RRP, HACP, CMS quality and patient experience star rating.
• As HQR system administrator, downloads and saves CMS hospital specific reports, assists with interpretation of all reports, analysis, and conduct related quality performance improvement.
• Reviews medical record documentation to evaluate compliance with established quality measures criteria; provides analysis/drill down and recommends areas for improvement: leads performance improvement initiatives.
• Evaluates, validates, and ensures submission of Electronic Clinical Quality Measure (eCQM) in accordance with CMS requirements.
• Evaluates compliance with CMS structural measures and implements plan for ongoing compliance.
• Assists the Director and Quality Data Analyst with CMS, State, and Joint Commission (ORYX) data submission as needed.
• Ensures complete and accurate data is collected and maintained for CMS quality measures including abstracted quality measures.
• Designs and delivers education to medical and clinical staff regarding effective documentation in the medical record related to quality measures; reinforces interpretation of quality measure criteria to nursing and medical staff as needed.
• Serves as the Quality Improvement Organization (QIO) liaison as needed.

Serves as Chair of Sepsis Committee, prepares agenda and meeting materials, facilitates meeting, and manages follow-up items.

• Performs sepsis chart abstraction, clinical data compilation and analysis to generate reports and identify trends to share with operational leaders, Providers and designated quality Committees.
• Develops evidence-based care sepsis protocols, educates clinical staff, tracks patient outcomes, and ensures compliance with CMS sepsis quality measure (SEP-1) as needed.

Maintains working knowledge of Leapfrog Hospital Survey requirements and Leapfrog Hospital Safety Grade process and outcome measures.

• Works collaboratively with process owners and the Patient Safety Specialist to complete the Leapfrog Survey as required; ensures Leapfrog requirements are met; maintains required evidence documents.
• Works closely with Informatics/IT to coordinate the Leapfrog CPOE test as required; identifies and prepares internal team for testing, develops and implements plans to optimize test score.
• Analyzes Leapfrog safety data to identify trends, gaps, and actionable improvement strategies; creates summary reports for stakeholders and leaders.
• Translates analysis of Leapfrog safety data findings into measurable performance improvement plans to enhance the hospital's overall safety culture and Leapfrog safety grade.

In partnership with the department Director and Manager, assists with survey readiness and survey management activities.

• Using established problem‑solving methodologies, leads and/or assists with multidisciplinary performance improvement teams.
• Performs project‑based chart review and staff education in support of performance improvement initiatives.
• Assists with agenda planning for the hospital Quality Committee and presents reports as assigned.
• Effectively manages assigned projects with a level of independence in performance of the role and with a problem‑resolution approach.
• Actively participates as the department representative on designated multidisciplinary teams and Committees.
• Supports clinical operations and clinical initiatives as assigned.
• Attends required hospital‐wide orientations, meetings, and in‑services.
• Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest trends in field of expertise.
• Other duties as assigned to include coverage of essential Department functions and services.

• Minimum Required
  
  Education:
  
  Completion of an accredited Registered Nursing program. Bachelor of Science in Nursing (BSN) preferred; experience in lieu of degree may be considered.
• Preferred Education:
  
  Not Applicable.
• Experience:
  
  3+ years data abstraction, informatics, or EMR documentation analysis; 5+ years clinical nursing experience.
• Working knowledge of basic business software such as Excel, PowerPoint, and Word. Knowledge of performance improvement methodologies preferred.

Applicants must be licensed to work as a Registered Nurse in the State of Tennessee and must obtain CPHQ or CPSS certification within 18 months of hire and remain active throughout employment.