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Registered Nursing
Cardiac Service Line
Full Time
8 Hour Shift
Rancho Mirage, CA 92270
Job #
  • Job Objective: A brief overview of the position.
    • The Quality Outcomes Analyst will assist in measuring and analyzing clinical data to improve quality of patient care and cost-efficiency for the Cardiac Service Line.
  • Reports to
    • Cardiac Service Line Administrator
  • Supervises
    • None
  • Ages of Patients
    • None
  • Blood Borne Pathogens
    • Minimal/ No Potential
  • Qualifications
    • Education
      • Required: BSN or MSN
    • Licensure/Certification
      • Required: California RN license
      • Preferred: Healthcare Quality Certification (CPHQ), Certified Professional in Patient Safety (CPPS), or other relevant certification
    • Experience
      • Required: Two years’ experience in performance / quality improvement activities and/or one year experience as a registered nurse, and/or two years experience in healthcare analytics.
  • Essential Responsibilities
    • Demonstrates compliance with Code of Conduct and compliance policies, and takes action to resolve compliance questions or concerns and report suspected violations.
    • Participates in regulatory body surveys (e.g. Joint Commission, California Department of Public Health) and assist in monitoring of action items as requested.
    • Coordinates the Joint Commission (TJC) readiness education activities (e.g. audio conferences).
    • Assists with TJC Periodic Performance Review (PPR) and disease specific certification process by providing structure and process to organization stakeholders.
    • Assures accreditation survey reference-documentation binders are updated routinely.
    • Coordinates and schedules TJC tracers, including distribution of results and requests for follow-up from various department.
    • Facilitates meetings/projects that support TJC, CDPH, CMS and other regulatory readiness (e.g. Sentinel Event Alert Gap Analysis/ Action Plan Teams, Proactive Team Assessments and Mock Survey Response Teams).
    • Researches current findings of best practice and provide this information to appropriate clinical performance improvement teams.
    • Acts as facilitator and minute keeper for PI teams as required.
    • Analyzes, disseminates, and presents hospital outcomes data using statistical tools (i.e. process control charts, descriptive statistics, etc.) in an appropriate manner, as requested.
    • Prepares reports illustrating quality measures, data and recommendations.
    • Implements tracking systems to measure the effectiveness of interventions.
    • Communicates with team members and participates in appropriate committees to report process-outcome information.
    • Provides education to customers regarding process-outcomes data, specific data elements and other issues as identified.
    • Supports Root Cause Analysis process as requested.
    • Documents conclusions, recommendations and actions of Root Cause Analysis Meetings and distribute to appropriate individuals for follow up as requested.
    • Assists with projects supporting the Quality Department (e.g. identification of clinical financial-process measures to improve clinical outcomes and cost-efficiency, cost analysis based on research and financial data).
    • Assists with Quality Council agenda, minutes, follow-up, and related reports for medical committees and Board of Director, as directed.
    • Acts as a quality improvement leader and is a resource to the hospital, and the medical staff regarding TJC, CMS, and Title 22 standards.
    • May support Medical Staff Quality Improvement/Peer Review Committees as appropriate
    • May be responsible for core measure abstraction
    • May assume coordinator responsibilities for the Sepsis core measure
    • May act as an assistant to the Infection Preventionists
    • Performs other duties as assigned.