Clinical Quality Specialist

Essential Duties and Responsibilities

These duties and responsibilities described below represent the general tasks performed on a daily basis; other tasks may be assigned.

Quality Management

• Develops and maintains current knowledge of CMS and State quality measure requirements to include data interpretation and application to effectively evaluate compliance with all measures.
• Serves as a resource for CMS quality programs to include IQR, OQR, PI, VBP, RRP, HACP, CMS quality and patient experience star rating.
• As HQR system administrator, downloads and saves CMS hospital specific reports, assist with interpretation of all reports, analysis, and conduct related quality performance improvement.
• Reviews medical record documentation to evaluate compliance with established quality measures criteria; provide analysis/drill down and recommend areas for improvement: lead performance improvement initiatives.
• Evaluates, validates, and ensures submission Electronic Clinical Quality Measure (eCQM) in accordance with CMS requirements.
• Evaluates compliance with CMS structural measures and implements plan for ongoing compliance.
• Assists the Director and Quality Data Analyst with CMS, State, and Joint Commission (ORYX) data submission as needed.
• Ensures complete and accurate data is collected and maintains for CMS quality measures including abstracted quality measures.
• Designs and delivers education to medical and clinical staff regarding effective documentation in the medical record related to quality measures; reinforces interpretation of quality measure criteria to nursing and medical staff as needed.
• Serves as the Quality Improvement Organization (QIO) liaison as needed.

Sepsis Abstraction and Quality Improvement

• Serves as Chair of Sepsis Committee, prepares agenda and meeting materials, facilitates meeting, and manages follow-up items.
• Performs sepsis chart abstraction, clinical data compilation and analysis to generate reports and identify trends to share operational leaders, Providers and designated quality Committees.
• Develops evidence-based care sepsis protocols, educating clinical staff, tracking patient outcomes, and ensuring compliance with CMS sepsis quality measure (SEP-1) as needed.

Leapfrog Safety Survey

• Maintains working knowledge of Leapfrog Hospital Survey requirements and Leapfrog Hospital Safety Grade process and outcome measures.
• Works collaboratively with process owners and the Patient Safety Specialist to complete the Leapfrog Survey as required; ensure Leapfrog requirements are met; maintain required evidence documents.
• Works closely with Informatics/IT to coordinate the Leapfrog CPOE test as required; identifies and prepares internal team for testing, develops and implements plans to optimize test score.
• Analyzes Leapfrog safety data to identify trends, gaps, and actionable improvement strategies; create summary reports for stakeholders and leaders.
• Translates analysis of Leapfrog safety data findings into measurable performance improvement plans to enhance the hospital's overall safety culture and Leapfrog safety grade.

Other Duties

• In partnership with the department Director and Manager assists with survey readiness and survey management activities.
• Using established problem-solving methodologies, leads and/or assist with multidisciplinary performance improvement teams
• Performs project-based chart review and staff education in support of performance improvement initiatives.
• Assists with agenda planning for the hospital Quality Committee and present reports as assigned.
• Effectively manages assigned projects with a level of independence in performance of the role and with a problem resolution approach.
• Actively participates as the department representative on designated multidisciplinary teams and Committees.
• Supports clinical operations and clinical initiatives as assigned
• Attends required hospital-wide orientations, meetings, and in-services
• Maintains professional growth and development through seminars, workshops and professional affiliations to keep abreast of latest trends in field of expertise.
• Other duties as assigned to include coverage of essential Department functions and services.

Education and Experience

• Minimum Required Education: Completion of an accredited Registered Nursing program.
• Bachelor of Science in Nursing (BSN) preferred, experience in lieu of degree may be considered.
• Experience: 3+ years data abstraction, informatics, or EMR documentation analysis, 5+ years clinical nursing experience
• Working knowledge of basic business software such as Excel, PowerPoint, and Word.
• Knowledge of performance improvement methodologies preferred.

Certificates, Licenses, Registrations

Applicants must be licensed to work as a Registered Nurse in the State of Tennessee and must obtain CPHQ or CPSS certification within 18 months of hire and remain active throughout employment.