QUALITY IMPROVEMENT SPECIALIST- RN
JOB SUMMARY
To provide leadership, direction and assistance to the hospital and the medical staff to achieve the goals of the Performance Improvement (PI) Plan. Serves as a resource, an educator and a consultant. Ensures accurate data collection, analysis, and reporting to establish and maintain practice standards and organization-wide PI efforts.
RESPONSIBILITIES
Responsibilities related to medical staff PI
- Screens cases to identify issues for physician review, using criteria established by the medical staff and the NYS DOH.
- Initiates the peer review process by reviewing cases identified through the screening (mortalities, OR incidents, infections, etc.).
- Documents findings in MIDAS within established time frames.
- Identifies cases that present a serious concern (i.e. a possible sentinel event, an aberrant practice pattern, a potential lawsuit, etc.) and alerts the department director, medical staff leadership, and claims manager.
- Conducts special studies in collaboration with medical staff on issues that are high-risk, high-volume, or problem-prone. This includes chart review, data collection, data analysis, and graphical display.
Responsibilities related to risk management
Review incident reports on a daily basis.Identifies incidents that present a serious concern (i.e. a possible sentinel event, an aberrant practice pattern, a potential lawsuit, etc.) and alerts the department director, administration, and the claims manager. Initiates a more thorough review to clarify the circumstances.Creates MIDAS reports that will assist in the identification of patterns and trends.Responsibilities related to comparative performance
Reviews every case identified as meeting criteria for the core measures.Identifies opportunities for improvement (OFI’s) and attempts to resolve them with the appropriate physician and / or staff. Initiates strategies for correction of OFI’s.Ensures all physician-related OFI’s are in the respective quality profiles.Verifies the integrity of the data prior to harvest.Upon receipt of validation chart requests, re-reviews the selected medical records to identify any errors.Achieves a score of at least 85% on the validation studies. NOTE : Passing is 80%. Score >90%
Analyzes results of validation studies, identifying errors and opportunities for self-learning.Responsibilities related to organization-wide QI
Functions as a resource to other departments in support of their QI efforts. Serves as leader or consultant to a QI team.Analyzes data from other sources, such as Treo, Hospital Compare, etc. to identify patterns / trends and areas for improvement. Assumes leadership responsibility for identified projects.Supports on-site reviews by DOH surveyors, coordinating information, reviewing the medical record in question, and assisting the surveyor with all requests.Serves as a member of the Quality Council and / or other appropriate hospital committees.Assumes leadership for major projects, i.e. MIDAS manager.Other
Performs other related duties as assigned.QUALIFICATIONS / REQUIREMENTS
EXPERIENCE
Minimum of five years experience in Med / Surg nursing.Minimum of two years’ experience in quality improvement / risk management.EDUCATION
Graduation from an accredited school of nursing.BSN preferred.LICENSES / CERTIFICATIONS
Licensed in NYS as a Registered Professional Nurse
OTHER
If applicable, the individual performing this job may reasonably anticipate coming into contact with human blood and other potentially infectious materials. Individuals in this position are required to exercise universal precautions, use personal protective equipment and devices, and learn the policies concerning infection control.Computer literacy, including word processing and data management.Excellent oral and written communication skills.Excellent interpersonal skills; ability to deal effectively with individuals and groups.Initiative, creativity and flexibility.SPECIAL REQUIREMENTS
N / A
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