Quality Improvement Specialist

Description

Summary : Purpose :

Serves as a Healthcare quality and patient safety subject matter expert and resource to the hospital’s service lines. This position supports performance improvement efforts, quality, and patient safety initiatives designed to achieve top decile quality and safety outcomes. The Performance Improvement Specialist partners with Service Line Leadership, medical and department directors to review and analyze key performance indicators and Service Line Dashboards and to facilitate the development of effective improvement action plans. Population served is based on scope of services in the department but may be flexed as needed to achieve desired patient outcomes.

Responsibilities :

Essential Responsibilities :

• Facilitates the development, implementation and assessment of performance improvement strategies, plans and work plans utilizing the most appropriate tools (e.g. Plan-Do-Check-Act, Lean, Six Sigma Methodology)
• Facilitates interdisciplinary performance improvement teams.
• Develops tools to track key performance indicators for PI strategies, develops PI Project KPI definitions, numerator and denominator statements, data sources, and processes for collection & reporting. Develops tools to support audits, data collection / aggregate reports / reporting workbooks.
• Participates in and able to lead patient safety improvement projects
• Designs and participates in quality audits related to regulatory requirements, action planning monitoring and chart reviews and data collection activities, as appropriate.
• Identifies potential adverse events via various sources including the use of occurrence reporting system.
• Supports Patient Safety including facilitation of Safety Event Review Team (SERT) and Root Cause Analysis (RCA) processes. Completes all required documentation and regulatory reporting including monitoring of measures of success.
• Selects and recommends cases for peer review. Processes cases through the peer review process. Maintains all required records of peer review cases. Aggregates data from Peer Review.
• Gathers, reviews and analyzes data for entry into the required hospital, state and national databases
• Prepares agenda and maintains minutes from meetings.
• Strong understanding of data analytics and use of excel graph functions.
• Conducts Failure Modes Effects Analysis (FMEA), including process redesign and spread of initiatives, as identified as risk mitigation strategies.
• Supports all accreditation and regulatory compliance requirements such the Joint Commission and others. Serves as a guide and or scribe for regulatory site visits. Participates in development, implementation, and monitoring of plans of correction.
• Model Values (Personal, Connected, Imaginative, Agile) Demonstrates regular, reliable, and predictable attendance.
• Performs other duties as required.

Other Information :

Required :   Bachelors Degree with a minimum of 3 years work related experience.

CPHQ preferred.

Preferred :   Masters Degree.

Working Conditions :

Manual : significant manual skills / motor coord & finger dexterity

Occupational : Little or no potential for occupational risk

Physical Effort : Medium to Heavy effort. May exert up to 35 lbs. force

Physical Environment : Generally pleasant working conditions

Credentials : RN

Company : Northern Dutchess Hospital

Org Unit : 1090

Department : Quality Improvement

Exempt : Yes

Salary Range : $40.43 - $75.10 Hourly