Deaconess Health System

Job Details

Description

Campus: Memorial Hospital and Health Care Center

Department: Quality

Shift: Days

SUMMARY OF THE JOB:

The Clinical Quality Specialist is responsible for the collection, improvement, reporting, and accuracy of data collected for Medical Staff Quality, coordinating the Medical Staff, Advanced Practice Nurse and Physician Assistant Quality Processes, leading the hospital Patient Safety Program, and participating in patient safety survey data submission. The Patient Safety/Clinical Quality Specialist must be self-motivated and able to prioritize a variety of complex duties to meet deadlines. This position requires a high degree of diplomacy and tact as they will be interacting with people at all organizational levels within the hospital and outside organizations as well. A high level of factual dependability, accuracy and understanding of current regulatory body standards and requirements will be required to be successful in this role.

Medical Staff Quality duties include:

• Coordinates all activities associated with Provider Quality referrals, reviews, and reporting for the established Peer Review Process.
• Supports the Physician Ongoing Professional Practice Evaluation (OPPE) process by Coordinating Clinical Indicators for Physician OPPE with Medical Staff Departments, along with IT system managers, and Statit administrators. Supports the Allied Health OPPE as currently designed.
• Coordinates and supports provider Focused Professional Practice Evaluation (FPPE) as directed.
• Accurately navigates and abstracts data from the EPIC EMR.
• Coordinates with managers, directors, physicians, service line coordinators, coders, and staff members to ensure the accuracy of data, identify trends and improve clinical quality outcomes.
• Provides written and verbal reports for assigned clinical quality data committees, physicians and administrators as requested.
• Investigates and keeps current on evidence-based care, as well as quality improvement topics, tools and techniques.
• Ensures the confidentiality and security of patient and physician data gathered and stored electronically and on paper within the department.

Patient Safety duties include:

• Building patient safety program at Henderson campus to standardize with DHS to include Safety Advocates
• Daily Patient Safety Rounding
• Facilitate Root Cause Analysis, FMEA and other process improvement activities as needed
• Assist with nursing peer review process at DHH
• Coordinates and engages Henderson staff in Safety Culture Survey
• Collaborate with the DHS Patient Safety Coordinators and team efforts
• Report to and collaborate with DHS Patient Safety Committee
• Collect data and submit Leap Frog Survey
• Assist with QHIP Survey
• Assist with Kentucky Hospital Association survey and quality initiatives
• Collaborate with Nursing Quality with improvement processes
• Assist with monitoring and reviews of Midas entries to identify patient safety issues and trends which could negatively impact patient care

Education, Experience, Certificates, Licenses:

Bachelor’s degree in nursing or other health-care related field with at least five (5) years of related clinical experience and an active Registered Nurse license. Previous quality assessment and/or quality improvement experience desired.

Equal Opportunity Employer

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