Quality & Patient Safety Advisor (Per Diem)

Purpose of Position

In partnership with service line leaders and clinical content experts, the Program Coordinator for Quality and Patient Safety is responsible for service line’s overall quality and patient safety programs, including 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.

Description

• Quality Improvement Pay For Performance

• Responsible for the data abstraction of all applicable data measures with strict adherence to the specifications manuals provided by the regulatory body.
• Demonstrates applicability of methodology and reliability of definitions of the Core Measure data elements through careful monitoring of data entry into MIDAS (incident reporting system).
• Maintains current working knowledge of the changes in data definitions and variables for reporting data measures as assigned.
• Responsible for data accuracy, meeting submission timelines for all required entities as assigned by Executive Director.
• Responsible for searching external databases and web sites to keep current on all data submission requirements and specifications and using data abstraction tools to produce meaningful analyses and correlation of data.

• Process And Systems Improvement

• Collaborates with clinical educators, coders and other staff to serve as a resource regarding core measures requirements and other quality initiatives.
• Utilizes identified national benchmarks and standards of care in the development of action plans for QI/PI.
• Serves as a resource for developing and monitoring quality indicators.
• Supports a hospital-wide culture for continuous quality improvement.
• Prepares reports and improvement plans.
• Consults on quality monitors, including data collection, sample size, and analytical tools.
• Supports our Performance Improvement/Patient Safety /Quality initiatives and taskforces.
• Maintains proficiency in the use of MIDAS+, DataVision and, all other databases as assigned.

• Program Development

• Collaborates with respective Quality/Safety Program leaders, sponsors, advisors, content experts, and frontline champions on implementing evidence-based initiatives and monitoring process and outcome measures related to their program(s).
• Partners with Program leaders on program evaluation and identification of opportunities for improvement.

• Public Reporting And Internal Reporting

• Assesses clinical and non-clinical outcomes using the measurement systems established, including data collection analysis and correlation and dissemination of information to internal customers.
• Responsible for searching external databases and using data abstraction tools to produce meaningful analyses and correlation of data in simple, understandable graphic format for internal customers.

• Peer Review

• 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.
• Affords support to the Medical Staff and Department Chiefs with peer review activities.

• Regulatory Compliance

• Elicits support necessary to obtain valid, reliable data for reporting to regulatory agencies by remaining current with the regulations/standards and/or requirements as defined by these agencies eg. Center for Medicare and Medicaid (CMS), Board of Registration in Medicine (BoRM), the Joint Commission (TJC), Department of Public Health (DPH).
• Maintains current knowledge of all Regulatory changes/Updates and communicate changes to Hospital committees, taskforces and teams as appropriate.
• Coordinates activities with Executive Director for successful accrediting, licensing, and certification survey activities as assigned by service line (including but not limited to TJC, DPH, CMS, BoRM).
• Collaborates with Quality team and respective service line leaders in coordinating completion of the Semi-Annual Quality Analysis Reports for submission to the BoRM.
• Participates in Root Cause Analysis (RCS’s) and (Failure Mode and Effect Analysis (FMEA’s) as assigned and facilitates process change based on the findings of these activities.
• Provides support to staff for monitoring and summarizing the effectiveness of the process change.
• Provides feedback to management on process improvement initiatives, dashboard data, and indicator screening trends as assigned by service line or committee.

• Other Duties

• Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers in a manner that reflects Cape Cod Hospital’s commitment to CARES: compassion, accountability, respect, excellence and service.

Qualifications

• 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 Hospital with progressive experience in quality improvement preferred
• Minimum of 5 years of experience in Quality Database and/or system management preferred

Schedule Details

• Per Diem Hours, Rotating Days and Hours, Monday-Friday

Organization

Cape Cod Hospital

Primary Location

Massachusetts-Hyannis

Department

CCH-Quality / Patient Safety

Annual/Hourly

• Annual - Based on Full Time Employment

Hiring Pay Range

• 81100 - 105000