What are the responsibilities and job description for the Clinical Quality & Data Registry Manager: Cardiac Surgery position at MEDSTAR HEALTH?

General Summary of Position
Responsible for the management of clinical registries within MHVI in accordance with registry and regulatory requirements. Conducts analyses of trends against benchmark data and in collaboration with clinical leadership, identifies priorities for quality / performance improvement initiatives. Provides support and guidance to MHVI leaders and clinicians in accordance with the Clinical Performance Improvement Peer Review Program of the Medical and Dental Staff. Participates In Quality, Safety and Regulatory Readiness activities as appropriate. Supports MHVI system level quality & registry initiatives.

Primary Duties and Responsibilities

MANAGEMENT OF CLINICAL REGISTRIES:

Serves as the Registry Site Manager for the assigned registries: a) Maintains current knowledge of abstraction rules. b) Communicates information to clinical leadership related to changes in registry definitions, variables collected and risk adjustment models. c) Assigns access and updates institutional and individual profiles for clinicians/executive sponsor and others as appropriate. d) Maintains ongoing evaluation of and communication with third party vendors. Ensures accurate and timely submission of data into the Registry according to the Registry's targets and deadlines.

Ensures accuracy and integrity of registry data and clinical outcomes: a) Oversight of internal and / or external data abstraction specialists. b) Conducts monthly inter-rater reliability audits. c) Provides ongoing feedback to internal/external abstraction specialists. d) Develops tools to promote clinician compliance with documentation requirements. e) Assists in the design and management of data collection strategies.

In collaboration with physician champion, ensures registry protocols are followed and patients' PHI is protected.

Coordinates all aspects of governmental or registry initiated audits.

Supports regional MHVI efforts: a) Facilitates development of Registry Programs in other MHVI facilities as appropriate. b) Shares institutional best practices. c) Establishes standard work across service lines as appropriate.

DATA ANALYSIS AND PERFORMANCE IMPROVEMEMT:

Conducts analyses of trends against benchmark data and in collaboration with clinical leadership, identifies priorities for quality / performance improvement initiatives: a) Serves as an internal consultant to clinical leadership in the selection, analysis and use of benchmarking and outcome measures. b) Prepares appropriate oral and written presentations of data.

Researches and applies evidence-based and best practice models to guide project planning and implementation of interventions.

Participates in performance improvement teams.

PEER REVIEW:

Provides support and guidance to clinical and organizational leaders in accordance with the Clinical Performance Improvement Program of the Medical and Dental Staff: a) Assists clinical leaders in the development and implementation of comprehensive clinical and performance improvement peer review programs that are data driven and evidenced based. b) Develops and maintains a mechanism for identification of cases appropriate for peer review evaluation using information from the Patient Safety Event system, communication with physician and nursing leadership and the Risk and Quality Departments. c) Maintains the integrity and flow of confidential information that is used for peer review, focus professional practice evaluation (focus review), ongoing professional practice evaluation (OPPE) and reappointments for clinical departments. d) Aggregates and analyzes data from clinical and organizational databases for the purpose of clinical improvement, quality improvement and patient safety and to support the peer review process.

QUALITY, REGULATORY READINESS, PATIENT SAFETY:

Aggregates and analyzes data from clinical and organizational databases for the purpose of patient safety.

Participates in Regulatory Readiness, Patient Safety and regulatory survey activities as assigned.

Minimum Qualifications
Education

Bachelor's degree in a relevant field required
Master's degree preferred
Completion of the Institute for Healthcare Improvement: Open School is required within one year.

Experience

1-2 years performing analyses of patient population and/or hospital operation data required
1-2 years hospital clinical experience preferred
Strong experience with using Midas, UHC, and NRC Picker (or similar data bases), statistical analysis software, and Microsoft Office Suite required

Licenses and Certifications

CPHQ - Certified Professional in Healthcare Quality preferred or
Certif Patient Safety Officer - CPSO preferred or
Lean Sigma preferred or
Other American Society for Quality (ASQ) certification or relevant credential preferred

Knowledge, Skills, and Abilities

Familiarity with computers including databases, data collection, spreadsheet applications, and word processing

Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It’s how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.

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Clinical Quality & Data Registry Manager: Cardiac Surgery

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