Clinical Quality Improvement Coordinator
Required: Current Maryland license in good standing as Registered Nurse. POSITION SUMMARY Conducts quality assurance compliance audits, reviews policies and procedures. Responsible for training new employees or existing employees and implementing changes in work behavior or tactics. QI Coordinator monitors and manages projects that directly impact the facility’s performance while capturing metrics, statistics or data from personnel or work outcome. Principal Duties: 1. Supports systems designed to promote hospital-wide performance improvement. Via Review of Medical Record for issues related to quality and performance a. Performs concurrent and retrospective review of core measure patients and/or quality indicators in compliance with National Hospital Inpatient Quality Measures, Vermont Oxford Network and regulatory agencies such as Joint Commission, CMS, HQID project, MIEMSS, DHMH, HSCRC, etc. b. Knowledgeable about core measures, Vermont Oxford Network Data, etc., informing director of changes in protocol/data requirements and implications for clinical practice c. Participates in the education of medical staff, employees, leadership and Board on quality and performance indicators selected by the organization as well as the requirements and implications of these measures for clinical practice d. Performs retrospective and concurrent review of specific focused studies (including procedures, diagnosis and other studies) requested by medical staff, hospital departments and committees e. Flags and documents variances for selected indicators and variables for focused studies and implements indicators for medical staff and peer review including OPPE and FPPE as required by TJC f. Participates in data extraction for submission of required data electronically to Vermont Oxford, MIEMSS, NAS Collaborative and DHMH. Facilitates the organization’s responses in order to meet established time frames for submission g. Collects, interprets and reports data at specified intervals with accuracy and completeness h. Demonstrates proficiency in abstraction and interpretation of data reports 2. Interpretation of Clinical Data a. Identifies and interprets objective and subjective data found in the medical records b. Compares the identified data to established criteria to determine appropriateness of care c. Abstracts and reports PI information in appropriate format to detect patterns and/or problems in the delivery of care d. Identifies potential areas for change and improvement of the study design and data collection and makes recommendations e. Develops new ongoing quality projects and evaluates the appropriateness of indicators and criteria for quality monitoring 3. Development and maintenance of knowledge including Committee, Collaborative and Team Support a. Maintains current knowledge of PI strategies, principles, methodologies, techniques and data analysis. b. Maintains current knowledge of TJC, CMS, national quality indicator guidelines, Magnet, NANN, AWHONN, NAN and NDNQI and assesses compliance for assigned areas. c. Works with Leaders, Chiefs, Vice Chiefs and different service lines as well as facility Committee Chairs to organize and accomplish goals of required committee meetings, collaboratives and teams d. Executes effective improvement projects through multidisciplinary team collaboration e. Active participant in service line committee/council meetings and proactively provides reports and information as required by the committee or team and meets 90% attendance f. Assures that issues are communicated to appropriate committees or individuals and that issues have timely resolution g. Maintains peer review information in strict confidentiality and assures entry into database and PI file h. Coordinates assigned meetings, assisting with agenda and providing all data metrics from various committees. 4. Provides continued improvement consulting services to customers a. Evaluates referrals to the Quality Department. Refers issues to appropriate department Risk Management, Infection Control and Pharmacy. Follow up as needed. b. Maintains confidentiality of QA material c. Participates in CQI teams to improve organizational performance such as FMEA, RCA. All your information will be kept confidential according to EEO guidelines. Compensation: Like many employers, UMMS is being targeted by cybercriminals impersonating our recruiters and offering fake job opportunities. We will never ask for banking details, personal identification, or payment via email or text. If you suspect fraud, please contact us at careers@umms.edu.
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