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Job Description
Job Summary: Develops, implements and evaluates a comprehensive core measure program that ensures patients receive evidence based quality care for assigned hospital. Works collaboratively with senior management, steering committees and multiple cross-functional or cross-organizational multidisciplinary healthcare team members to ensure core measure compliance and the best possible patient outcomes are achieved. Employs principles of performance improvement, as outlined in the hospital-wide performance improvement plan, and conducts rounding in clinical departments as needed which includes monitoring Core Measure patients, and ensuring internal processes are followed. Develops and delivers training to appropriate staff members to ensure compliance with Core Measures and National Patient Safety Goals. Esssential Duties:- Coordinates a hospital-wide approach to designing, measuring, assessing and improving performance.
- Performs concurrent and retrospective quality and case reviews to assure that evidence based best practices are implemented timely for patients at assigned hospital.
- Collects, tracks, analyzes and reports on clinical compliance measures using The Joint Commission (TJC) and Centers for Medicare & Medicaid Services (CMS) Core Measure quality indicators. Performs data collection for core measures; enters required information for core measures into the database; extracts data for TJC core measure projects; and prepares and submits clinical reports within regulatory timeframes.
- Provides ongoing consultation and education with respect to the application of continuous quality improvement principles and practices and clinical core measures; explains and applies accepted methodologies (e.g. identify desired outcomes, analyze current processes/problems, collect/analyze relevant data, uncover root causes, develop performance/process improvement plan and implementation tactics, test recommendations and assess results.
- Assists in the planning and implementation of interventions to ensure evidence-based practices are implemented (i.e. Core Measures for Acute Myocardial Infarction (AMI), Heart Failure (HF), Pneumonia, Surgical Care Improvement Project (SCIP) Hospital Outpatient Department, Venous Thromboembolism (VTE).
- Researches and analyzes operational, market, clinical and financial data to provide senior leadership with potential areas of opportunity for transformational change in business processes, clinical outcomes and/or services of broad significance to the organization; assists and influences management in establishing short- and long-term business objectives/strategic plans centered in process improvement; gains consensus on performance improvement opportunities to be undertaken and assists in the prioritization of approved initiatives/projects.
- Coordinates all aspects of quality improvement initiatives/projects, including defining/measuring the problem, and developing/controlling outcomes-based process improvement and implementation work plans; identifies deliverables, milestones and dependencies to make sure projects are on track; keeps appropriate parties apprised of overall progress; ensures that results and cost benefits for assigned projects are clearly and accurately documented in accordance with established procedures.
- Provides direct support for core measurement improvement teams through activities such as: setting agendas, identifying resource needs, facilitating meetings, explaining methodologies/tools to be used, identifying issues, solving problems, providing analytic support and preparing team leaders.
- Meets with management staff in an effort to understand and resolve the challenges/barriers to the smooth execution/implementation of clinical core measurement activities; identifies problematic issues and recommends appropriate solutions.
- Performs data management and analysis and employs effective evaluation methodologies to determine whether current/proposed activities are consistent with strategic business objectives and/or project/work plans and produce the desired results; may develop new/interim strategies/approaches/plans to address and accommodate special or emerging needs/priorities; prepares reports of analyses, findings and/or recommendations.
- Keeps abreast of current trends impacting clinical core measure concepts/methodologies/tools to ensure that best practices are utilized in performance improvement efforts.
- Coordinates other organizational performance improvement projects of similar impact/complexity, working collaboratively with Clinical Effectiveness peers, as appropriate.
- Performs related duties as required.
Job Requirements
Education:- Bachelor's degree in Nursing
- Master's degree in a discipline related to the requirements of the position is desirable
Experience:- Five years of related clinical core measures/quality/performance improvement work experience in a large acute care hospital
- Or equivalent combination of education and experience providing the requisite knowledge/skills to perform the job
License/Certification:- Current Washington State Nursing license required
- Current driver's license valid in the state of Washington or other evidence of equivalent mobility
Additional Responsibilities: - Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times.
- Adheres to and exhibits our core values:Reverence: Having a profound spirit of awe and respect for all creation, shaping relationships to self, to one another and to God and acknowledging that we hold in trust all that has been given to us.Integrity: Moral wholeness, soundness, uprightness, honesty and sincerity as a basis of trustworthiness.Compassion: Feeling with others, being one with others in their sorrows and joys, rooted in the sense of solidarity as members of the human community.Excellence: Outstanding achievement, merit, virtue; continually surpassing standards to achieve/maintain quality.
- Maintains confidentiality and protects sensitive data at all times.
- Adheres to organizational and department specific safety standards and guidelines.
- Works collaboratively and supports efforts of team members.
- Demonstrates exceptional customer service and interacts effectively with physicians, patients, residents, visitors, staff and the broader health care community.
Catholic Health Initiatives and its organizations are Equal Opportunity Employers.
Shift: Days
Status: Part Time
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