Clinical Quality Specialist

AVH CORE VALUES ACCOUNTABILITY Takes responsibility for his/her actions, abides by the hospital#s guiding philosophies and policies, and follows through on commitments and physician orders.# He/she provides complete and accurate information to the Physician and/or other members of the work team. Takes personal pride and ownership in the quality of care and services provided to all internal and external customers. INTEGRITY Truthful, trustworthy, and principled. He/she demonstrates character, conviction, and honest and ethical behavior in all interactions with others.# The employee#s word can be trusted.# Behavior is consistent with these AVH Core Values. PATIENT CENTERED Passionate about patient care, creating positive impressions on a consistent basis and exceeding our patients# expectations. Exhibits courtesy and sensitivity to the needs of patients and their families, responds with a sense of urgency to patient problems, anticipates patient requirements, responds proactively and places the patient#s safety above all else. RESPECT FOR OTHERS Actively listens to others, takes other opinions into account, and communicates openly and honestly.# He/she demonstrates respect for others by being timely with communications, completion of tasks, and meeting attendance.# The employee is respectful of all physicians, colleagues, patients, visitors, and other stakeholders TEAMWORK Works collaboratively with physicians and other staff and assists whenever possible. He/she openly shares information, provides feedback and participates in appropriate decision making as part of a team of healthcare professionals. Hospital and departmental objectives are placed ahead of individual agendas. # # # # # # # Job Overview: The Clinical Quality Coordinator performs various duties including, but not limited to coordination of data collection, entry and preparation of quality and risk management reports and statistics. Serves as the HCAHPS data coordinator.# Assists with various Risk Management functions as well as hospital accreditation readiness. # Primary Scope of Responsibilities: Conducts reviews of specific quality/risk management indicators/projects for both hospital and medical staff as follows (not an all-inclusive listing): Acute care measures review (Sepsis, IMM); OP Measures (AMI) including all CAH required measures (manual or EHR data collection). Stroke Care Blood utilization review Transfer review (including EDTC/MBQIP) Other reviews as assigned Compiles reports and analyzes data to evaluate AVH#s performance in quality improvement, with duties including but not limited to: Quality indicator review (as noted above) HCAHPS Coordinator duties include: Managing the HCAHPS vendor for patient satisfaction surveys Ensuring timely reporting to the vendor of all needed patient information for the surveys Coordinates results reporting back to department managers: Assists with data analysis Educates and serves as a resource to all department managers for the patient satisfaction surveys. Compiles reports for the AVH Scorecard and Clinical Quality Committee. Submits reports, as required to outside entities (Press Ganey, CMS, State, MBQIP, HQIP, and TJC), as directed, and as per reporting schedules. Leads and/or facilitates clinical performance improvement teams/taskforces as indicated. Prepares and submits reports to Clinical Quality Committee, and Medical Staff Departments/Committees, as assigned. Provides feedback to staff regarding deficiencies in reviews (abbreviation use, VORB, Universal Protocol, etc) Facilitates MS/Allied Health Staff# peer review (chart review) at PRC meetings as follows: Pulls records, routes said records, records meeting minutes, and routes follow up as per set procedure and current indicators.# Facilities OPPE data collection and routing of reports, as per AVH policy. Also assists with chart review/proctoring of medical staff by routing records to appropriate physician for review (per set policy and direction by supervisor). Assists with data capture and review of Occurrences (including medication events), RCA, and FMEA, as assigned including the following: Organization and maintenance of confidential data base for occurrence reports, FMEA, and RCA Maintains listing of product recalls and routes them to appropriate departments for follow up, as appropriate. Ensures appropriate follow up is complete Assists with review of the clinical component of patient complaints and grievances, as assigned. Maintains data base Assists with accreditation compliance and readiness including TJC, CMS, and other healthcare accrediting bodies, as assigned. Assists with other duties: Minute taking at special meetings Attendance and minute taking at Safety Committee meetings. POPULATION SPECIFIC CRITERIA Demonstrates the ability to assess and interact with customers of all ages, recognizing language and learning barriers, and technology challenges. Able to state his/her duties during a code pink drill. # Minimum Qualifications: 3-5 years quality improvement experience in healthcare field required. Ability to use PI tools such as rapid cycle improvement, PDCA, Lean, RCA, and FMEA preferred. Working knowledge of core measures and other healthcare quality indicators preferred. Strong background in clinical documentation methods (EMR or paper record) preferred. General office/clerical experience, in a hospital/healthcare setting with excellent skills utilizing Microsoft programs (excel, PowerPoint, word) required. General working knowledge of accreditation requirements/regulations of Joint Commission and CMS preferred. Ability to concentrate and show attention to detail required. Relatively high degree of analytical abilities required. Strong interpersonal skills required Ability to work independently required. Ability to read and communicate effectively in English required. Strong medical terminology background required # Education/Certification Requirements: Degree in Nursing or other related allied health science related experience preferred CPQH certification required within one year of hire Working Conditions: Normal patient care environment with little exposure to excessive noise, dust and temperature May be exposed to communicable diseases through normal or careless performance of responsibilities May be exposed to mechanical dangers associated with mechanical devices May be exposed to stressful situations #