Quality Improvement Manager - Clinical Effectiveness - Full Time - 1st Shift

Job Summary

A professional who is responsible and accountable for the coordination, implementation, and analyzes quality improvement programs for the healthcare organization. Primary focus on clinical effectiveness initiatives and process to improve the quality of care, to enhance communication, to promote education, and to demonstrate improved organizational performance. Responsible to work with hospital Officers, Directors, Medical Directors, and Associates to identify opportunities, implement solutions, analyze data and processes, monitor progress and evaluate effectiveness of Organization-wide clinical effectiveness activities. Will oversee the submission and analysis of the following programs, Leapfrog, Kentucky Hospital Association initiatives, CMS and TJC reporting including the STAR watch reports. Will supervise the performance improvement reviewers and Data Analyst. Exhibits the F.I.R.S.T. values (Friendliness, Innovation, Respect, Service, and Trust).

Competent Nursing

1. Serves as a patient advocate.
2. Accountable for problem solving and critical thinking.
3. Uses evidenced based practice and pursues new knowledge including but not limited to:
4. Participates in data collection and performs research/pilots and creates new projects;
5. Shares research findings with others for the development of policies, procedures, and practice guidelines for patient care.
6. Systematically evaluates clinical care by: Understands the performance improvement process; Collects and monitors data for quality and effective clinical care; Implements activities to enhance the quality of clinical care.
7. Participates with interdisciplinary teams that evaluate clinical practice or health services.
8. Demonstrates knowledge and executes the unit's standards, policies and procedures.

Respect/Dignity

1. Defends patient rights and improves care on the unit and in the Organization.
2. Exhibits trustworthy behaviors, as noticed by colleagues, patients, and their families.
3. Assumes responsibility for personal health behaviors.
4. Demonstrates optimism and is adaptable to changes made in the department.
5. Shows genuine concern for colleagues, patients, and their families.
6. Maintains patient confidentiality within legal and regulatory parameters and delivers care in a nonjudgmental and nondiscriminatory manner that is sensitive to patient diversity.

Patient Safety

1. Promotes a culture of safety through identification of adverse events that warrants disclosure.
2. Reports incidents, "near-misses", and other critical and adverse outcomes by utilizing standardized methodology

Shared Nursing Leadership

1. Embraces new concepts by making efforts to become a self-directed, creative, progressive and visionary thinker.
2. Fosters innovation by motivating and inspiring others.
3. Pursues advanced education, professional membership and certification, as available.
4. Skilled in decision making abilities and exhibits a positive character.
5. Contributes to a supportive and healthy work environment for Associates.
6. Values and respects all levels of nursing.
7. Provides input regarding the Associate’s performance appraisal/competency review.

Communication/Collaboration

1. Maintains honest, exemplary interpersonal skills while providing open and clear communication of relevant facts.
2. Maintains and participates in a strong teamwork environment.
3. Accepts instruction and suggestions with optimism in an approachable manner.
4. Asks questions when clarification/instruction is needed.
5. Maintains composure during demanding periods of time.
6. Acts as a positive role model to implement and sustain change in the work environment.
7. Contributes to the achievements of the goals, mission, vision, and philosophy of the Organization.

Positive Outcomes

1. Demonstrates a commitment to professional and ethical accountability. Maintains and expands knowledge and skill.
2. Identifies opportunities for cost containment on unit meeting budget goals.

Teamwork

1. Utilizes team discussions to establish goals and develops mutual trust and loyalty among colleagues.
2. Promotes and maintains a positive team environment. Exemplifies strong interpersonal skills:
1. Collaboration in a non-defensive manner;
2. Flexible in assignments and understands compromise;
3. Responds to direction;
4. Exhibits congenial, humble and resilient behaviors.

Essential Functions, Duties and Job Responsibilities

1. Guide compliance with external reporting requirements (Premier, Centers for Medicare and Medicaid Services (CMS), The Joint Commission (TJC), State of Kentucky, etc.
2. Runs reports, analyze reports from CMS Quality Net, Premier in order to create a change management approach regarding quality initiatives.
3. Oversees the accurate data submission reports to the various internal and regulatory agencies including Premier, Quality Net, KHA initiatives, etc.
4. Leads all performance improvement initiatives including CMS, TJC abstraction, Insurance Quality Initiatives (Q-HIP/Anthem), Leapfrog submissions and clinical quality Meaningful use elements.
5. Analyzes leapfrog and starwatch reports, creates trend analysis, action plans for improvement, organizes performance improvement teams in order to achieve excellence status (Grade A on Leapfrog and 4/5 CMS Stars).
6. Oversees daily workflow assignments in order to meet compliance/submission deadlines.
7. Provides direction to the Organization’s leadership to foster the Organization’s mission and values through focused education, customer service, benchmarking, and interdisciplinary team work.
8. Supervises the Clinical Effectiveness Performance Improvement Reviewer and data analyst within the established fiscal and productivity guidelines of the Organization.
9. Collaborates with the leader of Clinical Effectiveness to assure that each CE initiative has an assigned physician champion, administrative support person and appropriate Organization personnel to accomplish an action plan for improvement.
1. Coordinates with the CE Medical Staff Coordinator (CEMSC) to attend medical staff meetings as appropriate to assist leaders and champions in the Quality Improvement process.
10. Conducts risk analyses, identify system and process variance trends, investigate patient events and unexpected outcomes to identify operational and clinical processes for quality improvement. Reports findings to the System Risk Manager and the leader of Clinical Effectiveness. Any physicians case review screening and findings shall be reported to the CEMSC.
1. Provides clinical collaboration to act on the reports from the incident/event reporting system.
2. Collects, aggregates and analyzes data from multiple sources to identify trends or patterns in order to determine appropriate action to prevent recurrence of identified risk.
3. Develops and implements a collaborative process with practitioners, clinical managers, clinical educators, ancillary staff and other Associates who have knowledge and expertise in specific clinical processes, methodologies and strategies.
4. Provides oversight and analytical support specific to the identification, evaluation, and reporting of a clinical variances to the System Risk Manager and the leader of Clinical Effectiveness.
11. Facilitates the implementation of a Process Improvement Team and understands how to develop and implement a Plan, Do, Check, Act (PDCA) methodology.
12. Researches evidence based standards of care related to priority focus areas and provides summary of the evidence in a format that is understood by end users.
13. Concurrently and retrospectively reviews and abstracts patient records to determine compliance with internal benchmarks, state and federal regulatory measurements or requirements.
14. Abstracts, gathers, aggregates, tracks, and trends data on select committee performance dashboards’ for the organization’s hospital committees including EMRMC, EMFLH, EMJBH and HOPD Clinics (i.e. disease specific committees). Organizes performance data into a format that is understood and usable by end users. Notifies the appropriate parties when thresholds are reached, identifying and suggesting the need for further analysis of data when appropriate.
15. Assists all departments in ensuring that pillar boards are being utilized and up in all departmental or assigned locations.
16. Works with all ancillary, nursing, medical staff, administration and quality department (s) on projects that would requires critical thinking with a clinical focus. Submits plan, findings and PDCA initiative to the Executive Director of Clinical Effectiveness. Projects shall be in alignment with the organizations strategic PI focus.
17. Serves as Performance Improvement chapter chairperson on the CAR committee to insure compliance with the regulatory entities and the Joint Commission.
18. Provides orientation, in-service training and continuing education related to clinical effectiveness program for all Associates in the Organization.
19. Acts as the project facilitator for performance improvement teams, responsible for providing “just in time” training for new teams.
20. Performs other clinical effectiveness duties as assigned.

The Joint Commission and Other Regulatory Requirements

1. Collaborates with the Safety Officer and the leader of Clinical Effectiveness to ensure the distribution of Sentinel Event Alerts released through The Joint Commission (TJC) to appropriate departments and facilitates system-wide Sentinel Event Alert responses in collaboration with appropriate facility and department representatives. Monitors the completion and gathers all teaching materials, etc. that complete the alert. All Sentinel Event Alerts shall be placed in the TJC binders at all hospital locations.
2. Abstract, Analyze, and Report data on certain Disease Specific Certification Committees.
3. Works with all ancillary, nursing, medical staff, administration and quality department on projects that would requires changes to meet accreditation requirements. Submits plan, findings and PDCA initiative to the regulatory coordinator. Projects shall be in alignment with the organizations strategic PI focus.

Management

1. In conjunction with Leadership, establishes multidisciplinary teams as needed to resolve, and administer a process for the receipt, documentation, tracking, investigation to produce evidence-based results utilizing clinical performance data.
2. Initiates the development of teaching tools in collaboration with clinical leaders to support the growth and understanding of performance improvement processes and goals system-wide.
3. Demonstrates optimism and is adaptable to changes within the department and the Organization.
4. Shows genuine concern for colleagues, patients and their families and responds to their requests in an ethical and timely manner.
5. Maintains patient confidentiality and privacy within legal and regulatory parameters and delivers information in a non-judgmental manner that is sensitive to patient and Associate differences.
6. Pursues specialty certification, professional membership, and continuing education.
7. Provides a positive role model to Associates by maintaining positive interpersonal relationships, accepting instruction and suggestions with optimism, and communicating clearly on relevant issues and facts.
8. Skilled in decision making, and directs, leads and evaluates Associates’ performance.
9. Provides peers with constructive feedback regarding their practice through both formal and informal interaction.
10. Embraces new concepts by making efforts to become a self-directed, creative, progressive and visionary thinker.

OTHER

1. Demonstrates a commitment to professional accountability and growth to maintain and expand knowledge and skills.
2. Contributes to the achievement of the mission and philosophy of the Organization and Department.
3. Maintains HIPAA level compliance on all departmental/committee discussions.
4. Contributes to the effective operations of the Organization by demonstrating dependability in job performance.
5. Demonstrates a commitment to incorporating the core concepts of patient family centered care into practice (dignity, respect, information sharing, and participation).
6. Demonstrates a commitment to the development and implementation of shared governance across the Organization.
7. Performs other related duties as assigned.

WORKING CONDITIONS, HAZARDS AND PHYSICAL EFFORT:

Works in a well lighted, ventilated and air conditioned office area, but visits to numerous Organizational departments are necessary. Must be willing to travel between three hospitals and other free standing clinics. Must be able to deal effectively with physicians and associates who are not in favor of change or perceived additional work load. Chance of exposure to blood and body fluids when completing reviews on the floor. Long periods in a stationary position and moving around the unit are required. Risks exposure to a high degree of interruption and stressful situations, time restraints, and monthly deadlines. Works a standard work week, but occasional extra time will be necessary. Must be able to move or position 25 lbs. independently.

CONTACTS WITH OTHERS:

Associates, other healthcare providers, administrative staff and hospital support services.

EQUIPMENT USED/SPECIAL SKILLS REQUIRED:

Computer skills including but not limited to word processing, spreadsheets, PowerPoint, departmental databases such as Premier. Clinical abstraction skills including medical terminology and strong organizational skills for multi-tasking of responsibilities.