Develops, facilitates and coordinates quality improvement programs (clinical, operational and service line) resulting in improved patient care, operations and patient experience. Collaborates with Hospital and Medical Staff on projects and quality initiatives relating to improved operations, processes and procedures. Facilitates activities associated with Core Measures program including abstraction and management and oversight of associated databases and systems. Assists with the completion of medical staff peer review process.
ESSENTIAL FUNCTIONS AND DUTIES
· Provides support to clinical department quality committees and other quality related teams; Prepare agendas, meeting materials, minutes, and related correspondence.
· As needed, performs data collection and abstraction for core measures, peer review, patient safety indicators and other quality indicators with an accuracy level of 90% or better following training; establishes and implements a system to communicate results in a real time manner; coordinates review processes and maintains tracking systems/logs keeping them updated with results.
· Prepares detailed reports, presentations and dashboards, presents findings at a variety of quality meetings and facilitates follow-up plans; communicates status of plans to responsible designated individuals.
· Supports Quality Specialists by having knowledge of core measure content and rules for documentation and best/required practices for related care delivery; develops and implements mechanisms to educate and update on a timely basis, all responsible administrative and clinical leaders when revisions occur. Refers to Quality Specialists as the experts in core measures.
· Maintains up to date knowledge of external requirements and regulations related to pay for performance initiatives; attends Midas, QIO, JCAHO/HFAP and other educational sessions that are offered on a regular basis.
· Assists in maintaining requirements with CMS to maintain the annual payment update; communicates issues to the leadership in Quality; works with the hospital's core measure vendor and Quality Improvement Organization (QIO) to resolve issues that may impact compliance with requirements such as sampling, response to required questions on QNET; Responsible for downloading QNET mail on a daily basis.
· Works with Information Systems (IS) to automate where possible the collection of data for core measures; establishes processes to test the validity of data of electronically abstracted data; works with IS on the implementation of meaningful use related to core measures.
· Interfaces with HIM to resolve coding issues that impact core measures, patient safety indicators and other quality related matters; maintains contact with HIM to assure that records requested for review by CMS and its agents are provided on a timely basis.
· Assists with the development of core measure training for individuals and departments. Serves as a core measure trainer.
· Utilizes and prepares quality improvement tools such as basic flowcharts, interprets results using control charts and other data analysis tools.
• Bachelor's Degree in Nursing or Health Information Management with Registered Health Information Administrator (RHIA) Preferred, other health related field.
• Associate Degree with at least two years Quality Improvement or related healthcare experience.
MINIMUM WORK EXPERIENCE:
• Two years of clinical or related hospital experience, with one-two years experience in quality improvement or related activities preferred.
• Demonstrated human relation and effective communication skills required.
• Knowledge of Quality Improvement tools and statistical analysis.
KNOWLEDGE & SKILLS: • Demonstrated knowledge of quality improvement principles and practices (project management, patient safety concepts, peer review, public reporting, data analysis, data management and statistical process control in healthcare.
• Demonstrated knowledge of external regulatory and accreditation agency rules and regulations.
• Demonstrated knowledge of facilitating and coordinating healthcare improvement projects with previous quality improvement project experience.
• Proficient computer skills with extensive experience using various software applications such as MS Excel, Word, Access, Power Point, Visio.
Schwab Rehabilitation Hospital is a freestanding, not-for-profit, 102-licensed bed facility onChicago’s West and Southwest Side that offers comprehensive inpatient and outpatient programs foradults and children. Schwab is a proud member of Sinai Health System and the first fully licensed andaccredited rehabilitation hospital in the Midwest.Our therapists see patients through the entire continuum o...f care, from acute inpatient admissions atMount Sinai Hospital, to inpatient rehabilitation and outpatient therapy services at Schwab. We alsohave a hospital-based rehabilitation-focused short-term sub-acute unit at Schwab that provides boththerapy and nursing services with exceptional outcomes.Our rehabilitation team takes a holistic, interdisciplinary approach to address the physical, cognitiveand psychosocial needs of each patient. Each patient is assessed and provided with a personalized careplan tailored to help achieve maximal independence and function. Schwab offers seven treatmentgyms featuring private treatment rooms, a warm-water indoor therapy pool, and an award-winningtherapeutic roof top garden.