Job Summary
Works with all hospital leaders and staff to aggregate, trend, and graphically report all manner of performance improvement data collection for the hospital. Works closely with PI teams as needed to help them successfully complete PI content for team projects. Assists Quality Director in regulatory preparation, committee preparation and participation as well as dashboard maintenance. Assists with the collection of concurrent and retrospective data. Works independently to enter data into required databases. Performs data abstraction related to required quality measurement activities, including data collection support and preparing data in a user-friendly format that can be used for clinical/operational decision-making. Responsible for meeting deadlines to assure that reports will be available for analysis in a timely manner.
Essential Functions
- Assists with preparation of data for submission to specific committees and other departments as needed.
- Works with all hospital leaders and staff to aggregate, trend, and graphically report all manner of performance improvement data collection for the hospital. .
- Prepares data and data collection tools in a user-friendly format.
- Assists with the collection of future data for submission meeting pre-established deadlines. Abstracts data with an RN and records in order to prepare monitoring summaries.
- Assists with development of reports for ongoing monitoring and evaluation for internal and external use.
- Supports regulatory compliance.
- Prepares and assists with the coordination and development of documents for compliance with current TJC and NJDHSS standards
- Maintains databases for internal and external quality purposes.
- Reviews data submitted to databases, ensuringintegrity.
- Prepares reports for committees summarizing data for display and review according to current statistical methods
- Utilizes web-based applications as appropriate
ED Responsibilities
- Regulatory Readiness:Assist with ongoing readiness for The Joint Commission, CMS, Department of Health,and hospital quality requirements as they relate to the Emergency Department
- Policy & Procedure Compliance:Help monitor staff compliance with Emergency Department policies,
procedures, and new initiatives and identify areas requiring additional education.
- Performance Improvement Projects:Participate in Emergency Department performance improvement
initiatives, including identifying opportunities, collecting data, tracking interventions, and monitoring outcomes.
- ED Throughput Meetings & Tracking:Participate in Emergency Department throughput meetings and assistwith tracking patient flow and key throughput measures. Monitor trends such as arrival-to-triage,door-to-provider, length of stay, disposition-to-departure, admission/transfer delays, and other identifiedthroughput metrics. Assist with identifying barriers to timely patient movement, documenting action items, andfollowing up on improvement initiatives.
- Patient Safety:Review and track Emergency Department safety concerns, incident trends, falls,
medication-related events, and other opportunities for improvement.
- Patient Experience:Assist with reviewing patient complaints, concerns, and satisfaction trends and helpdevelop improvement plans when appropriate.
- Staff Education:Help identify educational needs based on audits, quality findings, or changes in policies andassist with staff education and follow-up.
- Quality Meetings & Follow-Up:Assist with preparing information for Emergency Department quality meetingsand maintaining follow-up on identified action items.
- Corrective Action Monitoring:Help track quality-related action plans to ensure interventions are completedand sustained.
- Interdepartmental Coordination:Collaborate with Nursing, Quality, Risk Management, Infection Prevention,and other departments on Emergency Department-specific quality and throughput initiatives.
- Reporting:Provide the Emergency Department Director with routine updates regarding findings, throughouttrends, outstanding items, and recommendations for improvement.
Minimum Education/Certifications
BS or BA Degree or equivalent work experience required. Proficient verbal and written skills. Ability to work and communicated with all levels of people. Must possess analytical abilities, computer and organizational skills and the ability to prepare statistical summaries. Must possess knowledge regarding technology to support data entry and analysis, e.g., Microsoft Excel.
Other Duties
Please note that this job description is not designed to cover or contain a comprehensive listing of activities, duties, or responsibilitiesrequired of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.