BASIC PURPOSE OF THE JOBConducts concurrent and retrospective criteria-based monitors using established policies and procedures by reviewing medical records, abstracts, computer records, etc., for a variety of data. Under the supervision of the Quality Management Manager assists in managing the Hospital-wide occurrence monitoring program especially related to trauma registry and Vermont Oxford Neonatal Network.. Act as a resource to all medical and Hospital departments for quality assurance and medical staff peer review. Maintains the strictest confidentiality of all patient information reviewed. Promotes the concept of cooperation and develops open lines of communication with department employees, patients, visitors and other personnel within and outside the Hospital.
REPORTS TO- Manager-Quality Management & Patient Safety
JOB REQUIREMENTSSupervisory Responsibilities: NO
Minimum Education: Bachelors Degree required
Degree: Degree in Nursing Healthcare Administration, Public Health, Health Information Management Required or related field.
License/Certification Required: TN or Compact RN Licensure Required (if applicable), Registered Health Information Administrator (if applicable), Registered Health Information Technician (if applicable), Certified Professional in Healthcare Quality (preferred)
Minimum Work Experience: Minimum of 3 years experience, in an acute hospital setting or 2 years of experience in quality assessment required.
REQUIRED KNOWLEDGE, SKILLS, AND ABILITIES- Knowledge of clinical practice with ability to interpret clinical information.
- Must possess excellent verbal and written skills in order to communicate pertinent information appropriately to various levels of professional hospital staff.
- Proficient in MS Office (specifically Word, Excel, PowerPoint) and data base technologies.
- Must possess the ability to coordinate and analyze QM process and take an informal leadership role in promoting excellence in data and process quality control.
DUTIES AND RESPONSIBILITIES- Accurately and proficiently reviews clinical information both concurrently and retrospectively for use in a variety of quality improvement activities as required by the Hospital's PI plan, Joint Commission standards and third-party payor regulations.
- Documents occurrence screens and other information in on-line system, accurately, timely and with critical analysis to question or address inconsistencies or concerns.
- Queries/writes reports from clinical data bases such as CHCA,PHIS, Medisolv, Meditech, QRM and monitors database accuracy. Demonstrates strong abilities in compiling, analyzing summarizing and displaying data for review. Assists with Root Cause Analysis interviews and coordinates findings under the supervision of the Director
- Assists with education of new employees, medical staff and others on Quality Management and SPS/Destination Zero.
- Efficiently coordinates all aspects of data management for the Vermont-Oxford Neonatal Network within the requirements set forth by the system in conjunction with Chief Neonatologist.
- Serves as the hospital's trauma registrar and ongoing liaison with state/national expectations. Accurately performs trauma data abstraction and submission within Registry timelines.
- Optimizes peer review process with selected Medical Staff Committee chairs to include Mortality review, and Acute Care/Trauma. Optimization includes ongoing evaluation of review processes that minimizes physician time while maximizing results from their reviews and identifying/supporting physician champions for specific clinical issues
- Ensure timely completion of all review assignments, reports any deviations in completion schedule. Willingly performs additional focused reviews and specific studies as requested to support the Hospital's PI activities.
- Initiates performance case review for department specific indicators, occurrence screens, etc. Ensures timely completion of all review assignments, reports any deviations in completion schedule. Identifies the need and develops data collection tools for criteria based monitors.
- Willingly performs additional focused reviews and specific studies as requested to support the Hospital's PI activities.
- Attends and supports interdepartmental and medical staff committees as assigned. Shares event report actions to assist departments with prevention of future events.
- Interacts and intervenes with multidisciplinary health care teams as a facilitator in a purposeful goal directed fashion, including proactive risk analysis.
- Pro-actively assesses the need for, develops and conducts training relevant to Quality Management and Patient Safety improvements.
- Continually shows commitment to the Department by extending self when need arises.
- Maintains a consistent flexibility to the work assigned, accepting interruptions, or priority urgent requests professionally.
- Consistently optimizes time efficiently and effectively, and serves as a role model/resource for others.
- Consistently utilizes appropriate tools, techniques, resources/systems to achieve maximum results and teaches others to do so.
- Is viewed as a resource in department when dealing with issues of systems and resources and accomplishing tasks in the most efficient and effective ways.
PHYSICAL REQUIREMENTS- Note: Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.
- Light lifting, pushing and pulling is required for 10-20 lbs occasionally and frequent moving of objects of less than 10 lbs is required. Frequent sitting with some walking, standing, squatting, bending and reaching is required. Keyboard/computer use and/or repetitive motions may be required.
Come work where you can make a difference everyday.