Nursing Quality, Risk & Patient Safety Specialist (Full Time)

Principal Duties and Responsibilities

• Oversees the data collection of hospital pay-for-performance programs including but not limited to CMS Inpatient Quality Reporting, Outpatient Quality Reporting, Inpatient Psychiatry, Joint Commission and MassHealth.
• Reviews medical records to collect data for reporting quality measures, including both concurrent medical record review and periodic medical record review for audit purposes as well as medical record review for serious safety events.
• Trains, coaches, and supports clinical departmental leaders and staff clinical staff in reviewing clinical charts, interpreting quality data, and implement quality improvement initiatives to deliver excellence in clinical care.
• Provides concurrent monitoring of all externally reported measures and coaching/feedback on outliers.
• Serves as the primary liaison with external measure abstractors who perform primary data abstraction on performance measures including but not limited to Q-Centrix.
• Provide expert knowledge, leadership, mentoring to patient safety initiatives utilizing safety science and principles of high reliability.
• Provide hands-on support of quality and safety work to clinicians and teams.
• Contribute to metric development and dashboard creation and maintenance to reflect the improvement and safety work at Mount Auburn Hospital. Analyze data and prepare concise, accurate, and meaningful quality reports in accordance with quality improvement/management principles.
• Collaborate with multidisciplinary healthcare teams to rapidly identify risk, employ prevention and risk reduction strategies; assist in the monitoring of patient safety standard compliance.
• Utilize clinical criteria and aggregates data, in the analysis of quality and patient safety issues and evaluating opportunities for improvement.
• Conducts surveillance, chart reviews and education activities for patient safety and performance improvement; Participates in data collection, data review, analysis and event reporting.
• Remains fully informed of evolving national and local quality, patient safety, and risk management mandates and guidelines.
• Collaborates with persons clinically responsible for inpatient and outpatient departments as well as non-patient care support areas based on interpretation and evaluation of CMS, CDC, OSHA, ODH, APIC, TJC, and EPA guidelines, standards and/or regulations or other standards related to safe and effective patient care.
• Captures and coordinates implementation of assigned projects, including plans, and keeping improvement teams on track to produce deliverables.

Commitment to Care with Compassion Professional Standards

• Demonstrate courtesy, respect and presence: Make people feel at home when they wish they were.
• Listen and communicate with care: Let your words and deeds say “you matter to me.
• Reach out and offer help: Don’t just react. Act first.
• Take care of our environment: Help to build confidence in us and promote calm and healing.
• Consider and support coworkers: Through teamwork, cooperation and respect, we make each other stronger.
• Use respectful telephone etiquette: When you’re on the phone, our reputation is on the line.
• Respect people’s time: When people are waiting, every minute is an hour.
• Handle difficult situations with kindness and compassion: Listen and ease the person’s way to satisfaction and solutions.
• Protect confidentiality and privacy: It’s a matter of respect and the law.

Knowledge, Skills, and Abilities Required

• R.N. with experience in risk management, quality assessment, or utilization management.
• Strong spreadsheet, database, and statistical analysis skills.
• Ability to interpret and apply clinical data to improve patient outcomes.
• Experience with quality improvement methodologies and tools.
• Excellent communication and interpersonal skills.
• Proficiency in using electronic health records (EHR) and related software.