Clinical Quality Improvement Coordinator

Division:Eskenazi Health

Sub-Division: FQHC

Req ID: 20488

Schedule: Full Time

Shift: Days

Eskenazi Health serves as the public hospital division of the Health & Hospital Corporation of Marion County. Physicians provide a comprehensive range of primary and specialty care services at the 333-bed hospital and outpatient facilities both on and off of the Eskenazi Health downtown campus including at a network of Eskenazi Health Center sites located throughout Indianapolis.

FLSA Status

Exempt

Job Role Summary

The Clinical Quality Improvement Coordinator is responsible for development, implementation, monitoring and analysis of appropriate methods of quality assessment/assurance and quality improvement projects and activities as part of the Quality Management Program. This position reports to the Quality Manager.

Essential Functions and Responsibilities

Provides concurrent chart reviews on the hospital units indicating to frontline staff, Physicians and the Unit Manager of quality measures out of compliance to ensure timely follow up using both written and verbal communication along with sending weekly reports to the Unit Manager, Quality Manager and AVP of Quality and Clinical Excellence

Develops concurrent chart review audit forms and weekly report form to provide feedback to frontline staff, Physicians and the Unit Managers; investigates and analyzes deviations (both positive and negative) then communicates trends and opportunities in written reports to Unit Managers, Physicians and appropriate healthcare leaders

Provides education to specific groups for performance improvement such as at unit staff meetings, flyers with quality measure information and tips, Resident Training and skills fair; posts quality measure data on learning boards in hospital staff break rooms

Acts as a change agent with frontline staff, Physicians and Unit Managers with focus on documentation improvements and effectiveness

Responsible for development, implementation, monitoring and analysis of appropriate methods of quality assessment/assurance and quality improvement projects and activities as part of the Quality Management Program

Interacts with all internal and external customers in a caring and respectful manner in accordance with our Core Values philosophy

Provides ongoing support to the quality of care provided to our patients and families

Manages projects and activities for patient safety and quality

Participates in service excellence, accreditation activities and initiatives

Provides input and recommendations to the quality management team for quality and safety projects and initiatives

Manages various data projects, reports and dashboards pertaining to key performance indicators

Ensures that project plans include measurements of program and individual outcomes, productivity measures, and are in compliance with all applicable legislative and accrediting organizations

Works with direct supervisor to coordinate initiatives aimed at meeting or exceeding clinical performance measure targets (for example: CMS Core Measures)

Leads clinical quality improvement projects

Coordinates quality improvement and risk management activities

Leads teams through standardized quality improvement methodologies and quality improvement cycles

Conducts chart abstractions from medical records (example: CMS' Core Measures)

Identifies streamlining and process improvement opportunities in the data collection process which includes identifying successes, trends, and contributing factors then develops action plans, methods to control, target dates and conclusions

Completes targeted audits as requested and as deemed necessary by leadership

Collects, aggregates, analyzes and inputs data related to blood products, Core Measures, Specialty Physician Incentive Measures, Conscious Sedation, Mortality, Falls, Critical Lab Values and other databases or monitoring activities as assigned

Supports risk management and medical staff services

Job Requirements

Bachelor's degree in health care or business related field required; OR four years of experience working in quality, data analysis, managed care and/or utilization tracking

Active RN license in the state of Indiana required

Clinical Nurse Specialist Advanced Practice Certification preferred

One year of managing cross-functional projects required

Improvement plan development experience preferred

Lean or Six Sigma training preferred; or experience with Six Sigma or other quality improvement methodology

Two years of recent Quality Management experience preferred

Experience with Medicaid Managed Care preferred

CPHQ certification preferred or willingness to become CPHQ certified over time

KNOWLEDGE, SKILLS, AND ABILITIES:

Investigative, decision making, problem solving, organization and analytical skills required

Ability to establish and maintain credibility and build effective relationships

Excellent verbal and written communication skills in interactions with various levels of management

Ability to present data at staff, peer, management and committee level

Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field

Demonstrated knowledge of quality management processes

Strong PC skills (including Excel, Access, Visio, other reporting database management systems) required

Working knowledge of Continuous Quality Improvement / Performance Improvement process

Ability to work independently; ability to facilitate groups and work within teams

Ability to facilitate change

Ability to prioritize, coordinate, organize and manage multiple tasks/priorities simultaneously

Positive self-starter and service-oriented individual

Detail-oriented with strong critical thinking skills

Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence

Ability to perform research through appropriate internet search engines

Knowledge, Skills & Abilities

Investigative, decision making, problem solving, organization and analytical skills required

Ability to establish and maintain credibility and build effective relationships

Excellent verbal and written communication skills in interactions with various levels of management

Ability to present data at staff, peer, management and committee level

Knowledge of medical terminology; demonstrated competence/knowledge of healthcare field

Demonstrated knowledge of quality management processes

Strong PC skills (including Excel, Access, Visio, other reporting database management systems) required

Working knowledge of Continuous Quality Improvement / Performance Improvement process

Ability to work independently; ability to facilitate groups and work within teams

Ability to facilitate change

Ability to prioritize, coordinate, organize and manage multiple tasks/priorities simultaneously

Positive self-starter and service-oriented individual

Detail-oriented with strong critical thinking skills

Displays good judgment in apprising management of situations that are incompatible with established policies for which there is little precedence

Ability to perform research through appropriate internet search engines

Accredited by The Joint Commission and named as one of Indiana’s best employers by Forbes magazine for two consecutive years and the top hospital in the state for community benefit by the Lown Institute, Eskenazi Health’s programs have received national recognition while also offering new health care opportunities to the local community. As the sponsoring hospital for Indianapolis Emergency Medical Services, the city’s primary EMS provider, Eskenazi Health is also home to the first adult Level I trauma center in Indiana, the only verified adult burn center in Indiana and Sandra Eskenazi Mental Health Center, the first community mental health center in Indiana, just to name a few.