Quality & Patient Safety Advisor

Overview

Purpose of Position: In partnership with service line leaders and clinical content experts, the Program Coordinator for Quality and Patient Safety is responsible for the service line’s overall quality and patient safety programs, including regulatory compliance, data analysis, performance improvement efforts, and other service line activities and special projects to support a culture of safety and compliance with Pay for Performance, Regulations, National Patient Safety Goals, Process and Systems Improvement, Public and Internal Reporting, and Peer Review facilitation.

• Quality Improvement

• Pay For Performance – Responsible for the data abstraction of all applicable data measures with strict adherence to the specifications manuals provided by the regulatory body.
• Demonstrates applicability of methodology and reliability of definitions of the Core Measure data elements through careful monitoring of data entry into MIDAS (incident reporting system).
• Maintains current working knowledge of the changes in data definitions and variables for reporting data measures as assigned.
• Responsible for data accuracy, meeting submission timelines for all required entities as assigned by Executive Director.
• Responsible for searching external databases and websites to keep current on all data submission requirements and specifications and using data abstraction tools to produce meaningful analyses and correlation of data.

• Process And Systems Improvement – Collects, aggregates, analyzes, and reviews data for improvement opportunities.
• Coordinates efforts in the development and implementation of action plans to resolve identified clinical/process issues utilizing the PDCA rapid cycle methodology.
• Collaborates with clinical educators, coders and other staff to serve as a resource regarding core measures requirements and other quality initiatives.
• Utilizes identified national benchmarks and standards of care in the development of action plans for QI/PI.
• Supports a hospital-wide culture for continuous quality improvement.
• Facilitates and collaborates in the designing of new processes that develop/monitor quality indicators.
• Establishing innovative processes to improve quality.
• Preparing reports and improvement plans.
• Consulting on quality monitors, including data collection, sample size, and analytical tools.
• Supporting our Performance Improvement/Patient Safety /Quality initiatives and taskforces.
• Maintains proficiency in the use of MIDAS+, Data Vision and all other databases as assigned.

• Program Development – Collaborates with Quality/Safety Program leaders, sponsors, advisors, content experts, and frontline champions on implementing evidence-based initiatives and monitoring process and outcome measures related to their program(s).
• Partners with Program leaders on program evaluation and identification of opportunities for improvement.

• Public Reporting And Internal Reporting – Assesses clinical and non-clinical outcomes using the measurement systems established, including data collection analysis and correlation and dissemination of information to internal customers.
• Responsible for searching external databases and using data abstraction tools to produce meaningful analyses and correlation of data in simple, understandable graphic format for internal customers.

• Peer Review – Under the guidance of the CMO, assists the Medical Staff and Department Chiefs with peer review activities.
• Organizes findings, actions and recommendations and oversees the maintenance of the MIDAS peer review database. Provides trend analysis of physician-specific quality data for re-appointment purposes and performance improvement initiatives.
• Assists the Executive Director, Quality, the Medical Director, the Chief of Staff and the Chief Quality Officer to ensure the compliance of the Medical Staff with TJC Standards, DPH Conditions of Participation, OSHA regulations and the BoRM PCA semi-annual reporting as assigned.

• Regulatory Compliance – Elicits support necessary to obtain valid, reliable data for reporting to regulatory agencies by remaining current with the regulations/standards and/or requirements as defined by these agencies (e.g.,…