Performance Improvement Clinical Specialist (N/E)

Location: Kent Campus Hospital

Status: Relief 0 Hours

Shift: Days

SALARY RANGE: 35.98 - 58.81HOURLY

General Summary:

Facilitates commitment to an organization-wide quality/safety culture and strategy. Coordinates and participates in the collection of data from medical records, logs, databases and error reporting systems that support performance improvement and patient safety activities of the Hospital and the Bayhealth Medical Group (BHMG). Coordinates the collection of quality/safety related data for peer review and the medical staff reappointment process. Facilitates/coordinates teams focused on performance improvement/quality improvement work associated with clinical outcomes. Provides leadership to teams focused on improving CMS measures associated with Patient Safety Incidents (PSI 90’s), Hospital Acquired Infections, Readmission Rates, CMS Core Measures, TJC ORYX data and other clinical indicators as necessary. Is primarily responsible for the coordination of team effort, documentation of action plans/project management and tracking of completion of all activity. Interfaces with all levels of the organization to achieve desired goals. Under the oversight of the Manager of PI Clinical Assessments, the Performance Improvement/Patient Safety Clinical Specialist is an experienced clinician who is responsible for abstraction of key clinical data from patient charts required for internal and public clinical performance reporting, and for ongoing monitoring and analysis of quality of care and related operational processes. This individual regularly interfaces with Medical Staff and Administrative leaders in the identification of and follow-through on opportunities for improvements in the quality of care delivered at Bayhealth Medical Center. This position is responsible for organizing, compiling, documenting, and analyzing data to produce reports from which opportunities for quality/safety improvement, intervention and educational activities can be identified. Educates staff in continuous quality improvement and patient safety concepts, processes, and tools. As necessary, researches and provides education on state, federal and other regulatory agencies’ standards. Which includes TJC and CMS requirements. In collaboration with the Director of Accreditation Services, provides guidance regarding compliance activity. Utilizes the performance improvement methodology in training departments and multi-disciplinary teams. Participates as a member of Hospital and Medical Staff Committees, as assigned. Cross covers, as needed, to meet the responsibilities of the department as a whole. This position supports these activities in the inpatient or ambulatory/ physician practice environment as assigned.

Responsibilities:

1. Facilitates the participation of individual department, service or Medical Staff in organization-wide quality/safety activities. 2. Collaborates with Hospital, BHMG and Medical Staff leadership and key committees to develop long-range goals, objectives, and strategies for quality/safety improvement with specific department, unit, service-line or clinical area of focus. 3. Assists in the identification of specific organizational needs and priorities related to quality improvement and patient safety utilizing a variety of sources including, but not limited to, measurement data, variance reports, patient/staff suggestions, team recommendations, comparative data, regulatory standards/reports, focus groups and knowledge-based information. 4. In coordination with the Director of Accreditation Services, Utilizes Tracer Methodology to assess compliance with Accreditation Standards 5. Conducts concurrent and retrospective focused studies to evaluate and analyze targeted areas of performance. Analyzes data to identify trends and opportunities for improvement as assigned. 6. Prepares data into meaningful information using forms, reports, graphs, tables, slides, and other documents to communicate results. Presents, as appropriate, data results to administration, medical staff, departments, and committees. 7. Facilitates multidisciplinary teams or committees as assigned. Coordinates the development and documentation of action plans associated with desired actions and targets. Tracks performance and escalates barriers as necessary. 8. In collaboration with the Manager of PI Clinical Assessments, designs and assures the capture of quality/safety data for the Medical Staff reappointment process by working with the Medical Staff to identify, define, and determine the best method for collecting quality-related reappointment data. 9. Supports the dedicated Performance Improvement/Patient Safety Clinical Specialist for the medical staff peer review with the process of indicator screening, case identification and referral. 10. Educates and acts as a resource to all hospital and practice personnel on quality methodologies and regulatory/accreditation standards related to quality and patient safety. 11. Accurately abstract required clinical and administrative data elements from patient charts within assigned populations for CMS’ publicly reported measures. Chart abstraction and data entry to be accomplished within 30 days of patient discharge. Thoroughly screens electronically archived charts of clinical cases within targeted screening populations; clearly presents any cases warranting physician peer review. 12. Responsible for ensuring accurate data entry in internal tracking databases. Responsible for providing accurate and timely follow-up for all cases deemed physician peer review. Report aggregate CMS measure data to assigned Medical Staff Department and Committee meetings at least once per calendar quarter. 13. Keeps current on all CMS core measurement requirements and impact on documentation and communicating upcoming changes and potential or current issues to physicians, physician extenders, and nursing staff, if activities/clinical documentation may impact Bayhealth’s public reported performance measures. 14. Serves as an educational resource on the Core Measure, Quality, and Performance Improvement for internal and external audiences by developing educational material and delivering presentations. 15. All other duties as assigned, within the scope and range of job responsibilities.

Required Education, Credential(s) and Experience:

• Education: Bachelor Degree ; Nursing ;
• Credential(s): Registered Nurse ;
• Experience:

  Required: 5 years clinical acute-care hospital experience.
  

  Preferred: Clinical critical care experience. Previous Performance Improvement in healthcare experience

Preferred Education, Credential(s) and Experience:

• Education: Master Degree Master Degree Nursing Related field
• Credential(s): Certified Professional in Healthcare Quality Six Sigma Lean Black Belt Certified Six Sigma Lean Green Belt Certified Basic Certification in Quality and Safety
• Experience:

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