RN-Quality Outcome Analyst-Quality Improvement

Job Description:

Education:

Required: Bachelor of Science in Nursing (BSN) or Master’s degree in NursingRequired: Bachelor of Science in Nursing (BSN) or Master’s degree in Nursing Licensure/Certification: Required: California Registered Nurse (RN) licensure
Preferred: Healthcare Quality Certification (CPHQ), Certified Professional in Patient Safety (CPPS) or other relevant certification

Licensure/Certification:

Required: California Registered Nurse (RN) licensure Preferred: Healthcare Quality Certification (CPHQ), Certified Professional in Patient Safety (CPPS) or other relevant certification

Experience:

Required: Three (3) years of RN, performance/quality improvement or healthcare analytics experience
Preferred: Healthcare Quality Certification (CPHQ), Certified Professional in Patient Safety (CPPS) or other relevant certification Experience: Required: Three (3) years of RN, performance/quality improvement or healthcare analytics experience Preferred: Experience working with clinical outcomes data systems and resource management

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 facility-wide 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
• 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.

Essential Skils:

• Written and verbal communication skills
• Ability to set goals and work independently and efficiently with minimal supervision
• Ability to speak in front of groups with confidence and clarity
• Ability to adapt quickly to changing priorities and unexpected situations
• Knowledge of performance improvement tools, and the ability to use them effectively
• Ability to effectively communicate in a positive and professional manner
• Ability to apply screening criteria against the medical record
• Ability to abstract cases for presentation in committees and Root Cause Analysis meetings
• Ability to take accurate and comprehensive committee minutes and draft committee correspondence
• Ability to collect, analyze and disseminate data, including financial and statistical data
• General working knowledge of regulatory standards including Joint Commission, Medicare (CMS) and Title 22 (state) requirements
• Computer skills, to include data entry, spreadsheets, graphics, information systems