Quality & Patient Safety Advisor

About the Role

In partnership with service line leaders and clinical content experts, the Program Coordinator for Quality and Patient Safety is responsible for the service line’s overall quality and patient safety programs. This includes regulatory compliance, data analysis, performance improvement efforts, and other service line activities and special projects to support a culture of safety and compliance with Pay for Performance, regulations, National Patient Safety Goals, process and systems improvement, public and internal reporting, and peer review facilitation.

Responsibilities

• Quality Improvement & Pay for Performance
  • Data abstraction of all applicable data measures with strict adherence to specifications manuals provided by regulatory bodies.
  • Monitor data entry into MIDAS (incident reporting system) to ensure applicability of methodology and reliability of Core Measure data elements.
  • Maintain current knowledge of changes in data definitions and variables for reporting assigned data measures.
  • Ensure data accuracy and meet submission timelines for all required entities as assigned by the Executive Director.
  • Search external databases and websites to stay current on data submission requirements and specifications, using data abstraction tools to produce meaningful analyses and correlations.
• Process and Systems Improvement
  • Collect, aggregate, analyze, and review data for improvement opportunities.
  • Coordinate the development and implementation of action plans to resolve identified clinical/process issues using the PDCA rapid cycle methodology.
  • Collaborate with clinical educators, coders, and other staff to serve as a resource regarding core measures requirements and other quality initiatives.
  • Utilize national benchmarks and standards of care in developing action plans for quality improvement and performance improvement (QI/PI).
  • Support a hospital-wide culture for continuous quality improvement.
  • Facilitate and collaborate in designing new processes that develop/monitor quality indicators.
  • Establish innovative processes to improve quality.
  • Prepare reports and improvement plans.
  • Consult on quality monitors, including data collection, sample size, and analytical tools.
  • Support Performance Improvement, Patient Safety, and Quality initiatives and taskforces.
  • Maintain proficiency in the use of MIDAS+, DataVision, and other assigned databases.
• Program Development
  • Collaborate with Quality/Safety Program leaders, sponsors, advisors, content experts, and frontline champions on implementing evidence-based initiatives and monitoring process and outcome measures.
  • Partner with Program leaders on program evaluation and identification of opportunities for improvement.
• Public and Internal Reporting
  • Assess clinical and non-clinical outcomes using established measurement systems, including data collection, analysis, correlation, and dissemination of information to internal customers.
  • Produce meaningful analyses and correlations of data in simple, understandable graphic formats for internal customers.
• Peer Review
  • Assist the Medical Staff and Department Chiefs with peer review activities under the guidance of the CMO.
  • Organize findings, actions, and recommendations and oversee the maintenance of the MIDAS peer review database.
  • Provide trend analysis of physician-specific quality data for re-appointment purposes and performance improvement initiatives.
• Patient Safety & Regulatory Compliance
  • Ensure compliance with regulations/standards from agencies such as CMS, BoRM, TJC, and DPH.
  • Maintain current knowledge of regulatory changes/updates and communicate them to hospital committees, taskforces, and teams.
  • Coordinate activities with the Executive Director for successful accrediting, licensing, and certification survey activities (e.g., TJC, DPH, CMS, BoRM).
  • Collaborate with the Quality team and service line leaders to complete Semi-Annual Quality Analysis Reports for submission to BoRM.
  • Participate in Root Cause Analysis (RCAs) and Failure Mode and Effect Analysis (FMEAs) and facilitate process changes based on findings.
  • Provide support for monitoring and summarizing the effectiveness of process changes.
  • Provide feedback to management on process improvement initiatives, dashboard data, and indicator screening trends.
• Perform other service line/program responsibilities as assigned.
• Consistently provide service excellence to all patients, family members, visitors, volunteers, and co-workers in a manner reflecting Cape Cod Hospital’s commitment to CARES: compassion, accountability, respect, excellence, and service.

Requirements

• RN license required.
• Baccalaureate Degree in Nursing required; Master’s Degree preferred.
• CPHQ preferred or proven experience in quality/process improvement and regulatory compliance.
• Effective communication skills.
• Excellent presentation and facilitation skills.
• Demonstrated competence in quality data analysis and presentation.
• Minimum of 5 years of experience in a hospital with progressive experience in quality improvement preferred.
• Minimum of 5 years of experience in Quality Database and/or system management preferred.

Schedule

• 4-day work week, Monday–Thursday.
• No weekends or holidays.

Pay

Annual salary range: $81,100 – $105,000 (based on full-time employment).